Barts Health NHS Trust

PFD Addressee
Reports: 71 Earliest: Jan 2014 Latest: 10 Mar 2026

60% 2-year response rate (below 83% average). 56% of classified responses show concrete action taken.

Response Status (last 2 years, 10 reports)
Responded 6 No Response 2
AI Classification
Action Taken 56%
Action Planned 29%
Noted 14%
Disputed 1%
Based on 70 classified responses
PFD Reports Received by Quarter
PFD Reports
71 results
Surekha Shivalkar
Historic (No Identified Response)
2022-0006 7 Jan 2022 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's early departure contributed to a failure to identify a critically ill patient.
Margaret Toye
Historic (No Identified Response)
2022-0004 23 Dec 2021 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not implemented, despite known widespread non-compliance on the ward.
Paul Sartori
All Responded
2021-0123 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and potentially inadequate diagnostic tools in emergency departments.
Action Taken (AI summary) NELFT has completed and disseminated a dedicated learning pack on aortic dissection, while Barts Health EDs now display 'THINK AORTA' posters and incorporate the campaign into multidisciplinary teaching. The Heart Attack Centre feedback template has also been updated to prompt exclusion of aortic dissection. The Royal College of Emergency Medicine has worked to increase awareness of aortic dissection through communications, safety notices, and developing specific learning modules. It is also in the process of finalising new guidelines on the assessment of patients and identification of those requiring CT scanning.
Evadney Dawkins
All Responded
2020-0292 21 Dec 2020 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical renal monitoring was delayed for four days, leading to a Grade 3 acute kidney injury. The Trust's governance systems also failed to promptly investigate this as a serious incident.
Action Taken (AI summary) The hospital has established a second site safety nurse role focused on nursing education and deteriorating patients and implemented an AKI bundle standardising responses to patients with AKI. Handover templates and simulation training have been developed, and new medical examiner and deputy medical director posts have been appointed to improve patient safety governance. The Trust has supported nurse training in renal monitoring, improved accuracy of records via electronic systems, improved patient handover and consultant ward rounds. The Trust is subject to strengthened inspection assessment of NHS trust’s learning from deaths by the CQC.
Shyama Rampadaruth
All Responded
2021-0005 11 Dec 2020 Inner North London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A frail, elderly patient suspected of COVID-19 waited six hours in discomfort for dialysis. No attempt was made to contact family for temporary care, despite their proximity and willingness.
Action Taken (AI summary) Barts Health NHS Trust now swabs all dialysis patients weekly, isolates COVID-positive patients on a single site, and has access to portable dialysis machines. They have also started vaccinating dialysis patients during their sessions and are actively planning to increase dialysis capacity.
Ivan O’Neill
Historic (No Identified Response)
2020-0269 2 Dec 2020 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate patient monitoring due to a frail, restless patient being out of sight, combined with an insufficiently sensitive dialysis alarm, delayed detection of a critical bleed.
Amarbai Bhudia
Partially Responded
2020-0232 12 Nov 2020 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Poor communication of medical instructions, inadequate training for nursing and agency staff on NG tube management, and a failure to properly escalate concerns about its function were identified.
Action Taken (AI summary) Barts Health NHS Trust implemented a structured ward round template to improve communication and a teaching session on Nasogastric Tube Placement was delivered to teams on the wards. A comprehensive local induction pack was developed to ensure that all temporary workers have a robust induction to the clinical area.
Clara Moniatis
All Responded
2020-0221 3 Nov 2020 Essex
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring prompt clinical review after a PEWS alert.
Noted (AI summary) The Trust states that early senior review of deteriorating patients is critically important and they have shared learning widely among clinical staff; however, they believe that nothing could have prevented the patient's outcome.
Michael Robert Collins
All Responded
2021-0092 30 Oct 2020 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical report delivery poses a significant communication risk.
Action Taken (AI summary) The respiratory team developed a Standard Operating Procedure to ensure all investigation results are reviewed promptly. The trust Divisional Director for Imaging has reviewed the processes and has improved the system, which is now formally incorporated within the trust Standard Operating Procedure.
Moses Boardman
Partially Responded
2020-0160 11 Aug 2020 East London
Other related deaths
Concerns summary (AI summary) Failures in hospital discharge procedures for vulnerable patients included incorrect address records, inadequate transport checks, and poor communication with care providers. Patient monitoring was also insufficient, and CPR wasn't initiated when warranted.
Action Planned (AI summary) The Royal London Hospital departure lounge changed its practice to ensure that staff document address changes in the patients electronic record in line with trust practice and clarified in their SOP that when patients are discharged staff check the address they are going to with them directly. LBTH will reiterate the importance of adhering to the Failed Visits policy to commissioned providers at the next forum, and the lead commissioner will remind Sue Starkey House of the importance of informing the emergency duty team if a patient does not arrive as expected from hospital discharge.
Ibiyemi Ereoah
Historic (No Identified Response)
2020-0048 2 Mar 2020 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Insufficient gynae-oncology consultant cover led to a lack of advocacy in MDT meetings and delayed consultant reviews. There was no system to ensure timely consultant intervention for patients deemed unfit for surgery.
Keith Hill
All Responded
2019-0446 20 Dec 2019 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Poor communication between specialists, inadequate medical record-keeping, and insufficient senior support for junior pharmacists resulted in crucial medication decisions not being documented or administered.
Action Taken (AI summary) The Trust reviewed decision-making between teams, reinforced documentation of significant decisions, reiterated consultant support availability to junior doctors, and instituted a rota for senior pharmacist support out-of-hours.
KennethDaly
Partially Responded
2019-0348 23 Oct 2019 London Inner (North)
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Unclear advice from consultants regarding co-prescribing multiple opioids and a lack of tailored written guidance for patients on the risks of combined opioid use were identified.
1 response from Rochdale Boroughwide Housing Limited
Shahida Begum
Partially Responded
2019-0199 18 Jun 2019 London (East)
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical observations are taken, which is deemed a less safe system.
Action Taken (AI summary) The trust has changed procedures so vital sign records are taken and made available to the streamer before the streaming decision is made. They have also provided additional training for streamers on the importance of abnormal clinical observations.
Steffan Kuenzel
All Responded
2019-0002 29 Apr 2019 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The patient received insufficient specific guidance on safe alcohol reduction methods and was unaware of critical alcohol withdrawal symptoms beyond seizures requiring urgent medical attention.
Noted (AI summary) Barts Health NHS Trust acknowledges the seriousness of alcohol addiction and states that their public health consultant is working on improved health care packages for alcoholic patients, following successful packages for smokers.
Chand Ali
All Responded
2019-0085 7 Mar 2019
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Cyclizine, cautioned for severe heart failure, is routinely administered without individual risk assessment or monitoring of adverse outcomes. There has been no review of alternative antiemetics.
Noted (AI summary) The Trust reviewed the evidence for the caution in the British National Formulary regarding cyclizine use in heart failure patients and found the evidence limited. They will warn teams of the risks, but cyclizine may still be used when assessed as the best option.
Brenda Gowan
All Responded
2019-0064 25 Feb 2019 London (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate discharge planning for a stroke patient included insufficient social care, disregarded family concerns, unassessed falls risk, lack of community support, and unprovided essential safety equipment.
Action Planned (AI summary) The Trust will document care planning meetings, offer experiential training for carers including an overnight stay, and include carer guidelines in the discharge information. These changes will be reviewed within the monthly stroke governance meeting.
Gabriele Kreichgauer
Historic (No Identified Response)
2019-0082 22 Feb 2019 London Inner (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The patient was discharged without antibiotics due to missed checks, and an incorrect diagnosis from an internet resource led to ineffective treatment. The resource also lacked a clinician feedback mechanism for inaccuracies.
Norman Pirie
All Responded
2019-0030 18 Jan 2019 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A surgical cuff device was used outside manufacturer guidelines in a non-emergency procedure, increasing the risk of device failure and the need for high-mortality open surgery.
Action Planned (AI summary) The Trust will implement enhanced MDT review of device selection including non-IFU treatments, document the decision in the patient's record, and inform the patient and GP about treatment options.
Marian Hoskins
All Responded
2019-0005 9 Jan 2019 City of London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led to insufficient patient information on investigatory options.
Action Planned (AI summary) A new Trust policy on informed consent and supported decision making for elective surgical procedures is being drafted, clarifying that informed consent is a process over time in the outpatient clinic. St Bartholomew’s Hospital has committed to a programme of improvement for consent as one of their Key Objectives for 2019/20.
Dawn Gill
All Responded
2018-0354 16 Nov 2018 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital lacked a nursing care plan addressing the patient's likely continued drug use while admitted, and the drug chart went missing. A search of the patient's room also did not detect her body under clothing on the floor until hours later.
Action Taken (AI summary) Barts Health NHS Trust is reminding nursing teams about documenting suspected illicit drug use in care plans and handovers. They have reviewed the missing person policy and reminded nursing teams about the risks of making assumptions.
Angela West
All Responded
2018-0212 27 Jun 2018 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) High-risk surgery scheduled before a weekend led to care under reduced staffing, compounded by placement on a general ward and missing fluid balance charts, indicating dehydration issues.
Action Taken (AI summary) The out of hour’s surgical cover has been enhanced to ensure daily review of acute inpatients seven days a week, the junior doctor’s induction programme now contains a section around clinical escalation, the numbers of overall doctors in the surgery department have increased and there is a good mixture of skills sets throughout shifts, and that this specific case has also been presented through the mortality and morbidity meetings within surgery and medicine and continuing to be provided to all clinical staff.
William Bartram
Historic (No Identified Response)
2018-0174 6 Jun 2018 London (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Unclear processes for repeat blood samples in babies, failure to highlight abnormal test results, and inadequate discharge advice to parents led to missed critical health issues.
Freddie Dobinson-Evans
Partially Responded
2018-0078 14 Mar 2018 London Inner (North)
Child Death Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A critical genetic test result, indicating a pathogenic mutation, was misread as normal, leading to a diagnostic error that could have significant consequences for other children.
Action Taken (AI summary) Following concerns about miscommunication of genetic test results, the organisation met with the genetics lab at Great Ormond Street Hospital, who have changed the results format to address future directions in case of any abnormality, effective from 01/05/2018.
Mike Fell
All Responded
2018-0100 5 Mar 2018 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk of accidental opening.
Action Planned (AI summary) Barts NHS Trust has rewritten its policy on the use of central lines and three-way taps, stating that three-way taps should not be used on central lines but self-sealing injection ports should be used. They are also discussing with their current supplier a change in design to allow a clamp to be fitted; they are interested in working with us as they see this as a problem nationally which has not been raised before in relation to this complication. The RCoA will publish information on central venous access line safety in the Patient Safety Update and include these issues in the updated AAGBI guideline Safe Vascular Access. The FICM and ICS are developing national guidelines on the prevention, detection, referral and treatment of air embolism associated with central venous access.