Dear Mr Irvine

Re: Inquest touching upon the death of Mrs Evadney Dawkins

I write regarding your letter of 21 December 2020 regarding your concerns relating to the death of Evadney Dawkins at Newham University Hospital. Barts Health NHS Trust has learnt lessons following this case, and is confident the changes implemented and planned will significantly minimise the risk of a recurrence.

I will respond to your concerns in turn.

On 22nd July 2018, Mrs Dawkins was assessed to require renal monitoring, incorporating; a) Regular blood tests b) A renal ultrasound c) Fluid intake/output monitoring The 3 actions were not undertaken for 4 days, after which, it was discovered that the patient had deteriorated and had sustained a Grade 3 acute kidney injury.

There have been many changes to address poor handover and lack of knowledge around AKI on the site. Management of AKI is a key component of the Foundations of Excellence program of nursing education which has been rolled out to all areas However, it was acknowledged that further work needed to be done with the nursing staff to ensure that nurses were sufficiently able to recognise and monitor a renal patient to a high standard. To this end, a second site safety nurse role has been established with a particular remit of nursing education, with a focus on deteriorating patients.

The hospital undertakes frequent audits on nursing documentation, which includes fluid balance, and on NEWS2 for deteriorating patients to gain assurance that care is of a good standard and any deficiencies are addressed. In terms of medical training, recognition and treatment of deteriorating patients is very much the focus of our compulsory simulation days for Foundation and Core Medical trainees. The AKI bundle has been implemented on the site which standardises the response to a patient with AKI and which actions and escalation should be taken following identification. This will

22 February 2021

Mr Graeme Irvine HM Area Coroner for East London Walthamstow Coroners Court Queens Road Walthamstow London E17 8QP

Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES

include a supported database so that all patients with AKI can be monitored and compliance can be likewise be monitored.

Since moving to electronic records system in Autumn 2019 the process for documenting and completing patient records is more accessible and easier to manage, as information is recorded in the same place and legibility is guaranteed. For example, in relation to fluid management charts, input/output can be automatically entered on to the electronic records system, rather than having to rely on paper based charts, contained within the records. This system generates alerts when safe parameters are breached.

Regarding nursing handover, standardised ward handover templates have been developed and are in use. In terms of handover for doctors, these are now run by the most senior doctor present; they happen daily and there is a dedicated room for them to happen to avoid disturbances. Support for daily Consultant ward rounds has been agreed; recruitment to these posts is in process. There is also a huddle meeting in the operations hub each morning which gives an opportunity to hand over patients of particular concern. Furthermore we have undertaken simulation training with the whole MDT to improve communication.

The Trust’s governance systems did not assess to a case as a Serious Incident requiring investigation for 2 years.

We recognise that there was a failure to assess and grade Mrs Dawkins’s death correctly as a Serious Incident at the time it happened. We now have an established and robust system in place where unexpected deaths are taken to a Serious Incident Review meeting where they are considered by a multidisciplinary team. Where there is doubt, the hospital errs on the side of declaring the incident as a Serious Incident and investigating as such, de-escalating as appropriate.

Additionally we have appointed three Medical Examiners who review every death on the site. These roles are overseen by the Deputy Medical Director which is an additional new post, part of the remit of which is to give greater assurance around patient safety governance. In this way, deaths that do not meet the criteria for a Serious Incident are robustly reviewed. We believe that had these actions been in place at the time of the incident, it is highly likely that it would have been declared as a Serious Incident.

Thank you for bringing this to my attention and I hope that I have been able to reassure you in showing that we are actively working to ensure measures are in place, and are followed, to reduce this risk.

Dear Mr Irvine

Thank you for your letter of 21 December 2020 about the death of Evadney Dawkins. I am replying as Minister with responsibility for hospital care quality and patient safety and I am grateful for the additional time in which to do so.

Firstly, I would like to say how very sorry I was to read of the circumstances of Mrs Dawkins death and I offer my heartfelt condolences to her family and loved ones.

Your report raises matters of concern relating to the failure to adequately monitor Mrs Dawkins renal function when she was admitted to the Newham University Hospital (part of the Barts Health NHS Trust); and that the Trust’s governance systems did not identify what happened to Mrs Dawkins as a Serious Incident, requiring investigation.

In preparing this response, my officials have made enquiries with NHS England and NHS Improvement (NHSEI), to understand the action taken locally, and the National Institute for Health and Care Excellence (NICE), to understand the guidance that is available to support healthcare professionals to prevent, identify and respond to acute kidney injury.

I am advised that the Trust has taken learnings from Mrs Dawkins death and is confident that the changes it has implemented and planned will significantly minimise the risk of recurrence.

You will be aware from the Trust’s response that it has taken measures to support nurse training in renal monitoring and recognition and treatment of deteriorating patients; improve the accuracy and accessibility of patient records through an electronic records system; and, improve arrangements for patient handover and consultant ward rounds, among other actions.

I understand the Trust has acknowledged the failure to identify Mrs Dawkins death as a Serious Incident but that it considers that it now has systems in place that mean this is unlikely to happen again. For example, the Trust advises that a multi-disciplinary team now considers unexpected deaths to determine whether investigation under the Serious Incident Review process is appropriate. Additionally, the Trust has appointed three Medical Examiners who review every death within the Trust’s services. As you will know, medical examiners have been introduced to the NHS nationally to provide a new level of independent scrutiny of deaths. Furthermore, the Trust has created a new post of Deputy Medical Director with a remit to provide greater assurance on patient safety governance.

I am encouraged by the Trust’s actions and I am assured by the Care Quality Commission (the CQC), the independent regulator of quality, that it has followed up your report with the Trust, seeking assurances that it has taken action to address the concerns you have raised and minimise any risk to patients.

It is of course essential to patient safety that NHS Trusts review, investigate and learn from deaths thought to be due to problems in care. That is why, in 2017, the National Quality Board published national guidance on Learning from Deaths1, to introduce a more standardised approach.

From 2017-18, we have required NHS trusts to publish locally the numbers of deaths thought to be due to problems in care on a quarterly basis, and to evidence what they have learned and the actions taken to prevent such deaths on an annual basis in their Quality Accounts. This new level of transparency is fundamental to a culture of learning and ensuring the safety of NHS services. This policy is supported by strengthened inspection assessment of NHS trust’s learning from deaths by the CQC.

You may also be interested to note that a new Patient Safety Incident Response Framework2, to replace the Serious Incident Framework, is being developed to facilitate examination of a wider range of patient safety incidents in the NHS and to improve the quality of patient safety incident investigation and how organisations can learn and change as a result.

The Framework outlines how NHS organisations should respond to patient safety incidents, including how and when an investigation should be conducted. The Framework supports a systematic, compassionate and proficient response; anchored in the principles of openness, fair accountability, learning and continuous improvement. NHSEI is currently working with early adopters to pilot the new Framework and the learning from this pilot will be used to inform the final version of the Framework.

Finally, you may wish to note that since the death of Mrs Dawkins in 2018, the NICE has published guidance on Acute kidney injury: prevention, detection and management (NG1483, published December 2019). The guideline covers prevention, detection and

1 https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf

2 https://www.england.nhs.uk/patient-safety/incident-response-framework/

3 Overview | Acute kidney injury: prevention, detection and management | Guidance | NICE

management of acute kidney injury in children, young people and adults and is relevant to all settings where NHS funded care is provided.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

NADINE DORRIES MINISTER OF STATE FOR PATIENT SAFETY, SUICIDE PREVENTION AND MENTAL HEALTH