Chloe Every
25 Oct 2024 · Coroner Graeme Irvine · East London
This report repeats 2 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of nursing cover during weekends and holidays for staff with relevant learning disability training
“The Trust does not provide nursing cover during weekends and holiday periods of staff with relevant learning disability training.”
2. absence of contemporary nursing and medical notes
“The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of [the deceased]'s treatment. The extent of these lapses meant staff who made important treatment decisions could not be identified, and where staff could be identified, no contemporary account of their rationale for making treatment decisions could be located.”
3. irregular clinical observations
“The regularity of [the deceased]'s clinical observations fell well below the expected level. The lapses included a period of over 10 hours in which no observations were undertaken.”
4. enema performed without informed consent on unconscious patient
“[the deceased] underwent an enema on 8th May 2019 without informed consent being taken. The court found that [the deceased] was unconscious, before, during, and after the procedure, it is possible this procedure contributed to her death.”
5. inability to explain CPR criteria
“Nursing staff were incapable of explaining to the court the appropriate criteria that would have to exist before commencing CPR on an unresponsive patient.”
6. governance failure to identify patient safety incident
“Governance processes at the Trust failed to identify that [the deceased]'s death constituted a patient safety incident until months after her death. A mortality review authored by the Associate Medical Director on 17th May 2019 assessed [the deceased]'s care as good or excellent.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“During the course of the inquest the documentation relied on by the trust was lacking in detail and meant that it was difficult to understand her condition at key points or to understand the rationale for decisions.”
This report
“The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of [the deceased]'s treatment. The extent of these lapses meant staff who made important treatment decisions could not be identified, and where staff could be identified, no contemporary account of their rationale for making treatment decisions could be located.”
Closely relatedConfidence 0.90 · high
Earlier report
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation in determining what, if any consideration was given to the possibility that Mr [name redacted] was suffering from an infection.”
This report
“The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of [the deceased]'s treatment.”
Identical hazardConfidence 0.90 · high
This report
“Governance processes at the Trust failed to identify that [the deceased]'s death constituted a patient safety incident until months after her death.”
Later report
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”
Identical hazardConfidence 0.90 · high
This report
“Governance processes at the Trust failed to identify that [the deceased]'s death constituted a patient safety incident until months after her death.”
Later report
“A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework.”
Responses
2024-0578-Response-from-Barking-Havering-and-Redbridge-NHS-Foundation-Trust.pdf ↗· Barking
Stated action
“the Trust has put mitigations in place. The Trust provides mandatory training for all staff including both nursing and medical staff related to the care of patients with a Learning Disability.”
2024-0578-Response-from-DHSC.pdf ↗· Barking
Stated action · 2025
“BHRUT plan to recruit more learning disability nurses in 2025. They have created pathways to encourage and upskill existing staff due to the shortage of nurses going into learning disability training (RNLD).”