Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Peter Ross · 4 Nov 2022 · Graeme Irvine, East London
“Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr [name redacted].”
judiciary.uk/…/peter-ross-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Peter Ross (4 Nov 2022) · stated timescale: none stated
“has completed all the actions assigned to the department within the Trust's SI recommendations and subsequent Action Plan. If any scan is mis- reported, the Department uses it as a learning opportunity, and it is reviewed at the Departmental Radiology Event and Learning Meeting (REALM) and undertakes a process of peer review. The Radiology Department has reviewed Mr [name redacted] scans through its Governance process.”
judiciary.uk/…/2022-0354-Response-from-Barking-Havering-and-Red…
Stated action 2 · response to George Kearsey (9 Feb 2023) · stated timescale: completed
“Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by”
judiciary.uk/…/2023-0050-Response-from-Barking-Havering-and-Red…
Stated action 3 · response to Thomas Doyle (20 Oct 2023) · stated timescale: 9 November 2023
“An Internal Alert has been shared with staff via email, Alert reference Issued Date 9 November 2023 which details good record keeping standards that should be adhered to by all staff.”
judiciary.uk/…/2023-0397-Response-from-Barking-Havering-and-Red…
10 further stated actions are listed on the full chain page.
What recurred
- 9 Feb 2023 · George Kearsey · Graeme Irvine
- 20 Oct 2023 · Thomas Doyle · Graeme Irvine · Closely related · confidence 0.90 (high)
- 4 Jul 2024 · David Morris · Graeme Irvine · Closely related · confidence 0.90 (high)
- 25 Oct 2024 · Chloe Every · Graeme Irvine · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Peter Ross · 4 Nov 2022
“Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr [name redacted].”
Later · David Morris · 4 Jul 2024
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent.”
What happened next
No evidence found either way · stated action 1
“A positive culture to develop learning is vital to improve outcomes and comply with the recommendations of the Francis Report.1 As radiologists, we are constantly striving to improve the standards of service we provide to patients with a culture of learning, self-reflection and personal development. Humans will always make errors and radiologists are no different. They will also have moments of brilliance”
Standards for radiology events and learning meetings · rcr.ac.uk/…/bfcr201-standards-for-radiology-events-and-learning…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“The proportion of prescriptions which met the IV fluid prescribing bundle of care increased (3.8% to 22.9% [p=0.004]) and the legibility of the IV fluid prescription increased (28.3% to 56.3% [p=0.004]).”
CLINICAL · rcpe.ac.uk/sites/default/files/2024-11/wood%20rcpe.pdf
“## Keywords colloids, crystalloids, fluid management, overhydration, underhydration”
Fluid management on hospital medical wards - PMC - NIH · pmc.ncbi.nlm.nih.gov/articles/PMC4951872
“## Abstract Intravenous (IV) fluids are commonly prescribed drugs in healthcare. However, inappropriate fluid administration is associated with higher morbidity and mortality. *Fluid stewardship* is defined as a series of coordinated interventions for judicious IV fluid administration, with a primary goal of limiting the deleterious effects of inappropriate fluid prescription and fluid overload or”
Introduction to Fluid Stewardship | Springer Nature Link · link.springer.com/chapter/10.1007/978-3-031-42205-8_27
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“This article covers how to enable, disable, and customize the Barking Alert notifications for your Furbo Dog Camera 360. It is intended for Furbo owners who want to manage how often they receive pet alerts on their smartphones, or troubleshoot alerts that are not working.”
Set Barking Alert – Furbo Help Center · help.furbo.com/…/17469702997657-Set-Barking-Alert
“Bark alerts are not sent in real time. It may take some time to receive notifications as we analyze context, not just keywords.”
Reviewing alerts | Bark Technologies · support.bark.us/en/articles/13460975-reviewing-alerts
“Bark provides alerts to administrators on bullying, drug and alcohol-related content, weapons, self-harm, and much more.”
BARK For Schools | Did You Know? · youtube.com/watch?v=Nwvw15e_PPY
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “A video has been developed and was placed on the Trust intranet 27 November 2023 which shows - Medical Director (Patient Safety and Patient Experience), explaining the importance of good record keeping.”
“Do business records management affect business growth? Clement Mintah, [name redacted], Felicia Aloo, [name redacted] · 2022-03-10 · 17(3):e0264135 · DOI: 10.1371/journal.pone.0264135 · PMID: 35271595 · PMCID: PMC8912245 ## Abstract The implementation of a records management plan is an excellent approach to ensure small and medium-sized enterprises (SMEs) are sustained and continue to expand into huge or multi-national corporations.”
Do business records management affect business growth? · pmc.ncbi.nlm.nih.gov/articles/PMC8912245
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “A screen saver was agreed and appeared on all Trust computer screens week commencing 4 December 2023”
“The purpose of this standard is to set a minimum standard for protecting our computers with password protected screen savers. The screen saver logs out an active user after a set amount of time with no activity. By requiring a user to sign in when they return, it minimizes the risk of an unauthorized person using an active session while the authorized user is away. A password-enabled screen saver”
Information Technology - Screen Locking Standard - TROY · it.troy.edu/policies/screen-locking-standard.html
“A HIPAA screensaver is basically a screensaver that automatically turns on after a computer is left unattended for a period of time. HIPAA screensaver compliance is discussed below.”
HIPAA Screensaver | Free Download with Instructions · compliancy-group.com/what-is-a-hipaa-screensaver
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “All medical staff must complete a record keeping module on the Trust BEST learning management system that allows staff to undertake e learning module on their first day working at the Trust.”
“Complete the online learning modules series, Foundations for Medical Record Keeping. 3. Apply medical record requirements to your record keeping for one month.”
Foundations for Medical Record Keeping: Food Producing ... · cvo.org/…/Guide-Medical-Record-Keeping-Learning-Module-Food-Ani…
“GBS Medical Record Keeping Policy Approved April 2020 Page 1 of 8 GBS Medical Record Keeping Policy GBS Medical Record Keeping Policy Approved April 2020 Page 2 of 8 Contents Definitions 3 1. Introduction 4 Aims 4 Scope 4 2. Governance 5 3. Guidance and Standards 5 4. Responsibility and Practitioner Accountability 7 5. Medical Records Audit 7”
GBS Medical Record Keeping Policy · gbsnowsport.com/…/Medical-Record-Keeping-Policy-April-20-FINAL.…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses.”
“Hospital Sepsis Program Core Elements are essential to optimize patient care and help clinicians, hospitals, and health systems in efforts to improve the hospital management and outcomes of sepsis.”
Hospital Sepsis Program Core Elements | Sepsis | CDC · cdc.gov/sepsis/hcp/core-elements/index.html
“Provide educational materials to staff about sepsis emphasizing the importance of preventing sepsis through proper infection control and expressing concerns when an individual/patient demonstrates a change in health status.”
Staff education · betsylehmancenterma.gov/…/staff-education
“Trust Board papers 7th September 2011 - Barking Havering and ... # Trust Board papers 7th September 2011 - Barking Havering and ...”
Trust Board papers 7th September 2011 - Barking Havering and ... · yumpu.com/…/trust-board-papers-7th-september-2011-barking-haver…
No evidence found does not mean the action did not happen.
Evidence found · stated action: “The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure compliance with the Sepsis 6.”
“Sepsis screening is facilitated via Nervecentre. Clinical staff must undertake Nervecentre training to obtain an account. These accounts must not be shared because the electronic signature is applied to all actions in the system. Nervecentre training is available via the CITS portal.”
[PDF] Sepsis in Adult Patients Clinical Guideline - rcht.nhs.uk · doclibrary-rcht.cornwall.nhs.uk/…/SepsisInAdultPatientsClinical…
“The sepsis six care bundle has been adopted by hospitals in England and Wales for the management of patients with sepsis, with the aim of increasing survival when all elements of the bundle are achieved.”
A Snapshot of Compliance with the Sepsis Six Care Bundle in Two Acute Hospitals in the West Midlands, UK · pmc.ncbi.nlm.nih.gov/articles/PMC6686588
“Screening tools and automated alerts are available but are not in widespread use. Where clinical information is stored electronically, software systems can detect sepsis before the clinical team has suspected it.”
Appendix 2 - Invited evidence from the UK Sepsis Trust | Public Service Ombudsman · ombudsman.org.uk/…/appendix-2-invited-evidence-uk-sepsis-trust