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
Clear
PFD Reports
45 results
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.
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.
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.
Caliel Smith-Kwami
All Responded
22 Jan 2018 London (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical insulin and amino acid results were delayed due to lab analyser faults and unchased; the electronic record system failed to alert clinicians to new results, hindering diagnosis before discharge.
1 response from Barts Health NHS Trust
Harold Chapman
All Responded
2017-0377 28 Nov 2017 London Inner (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Patient emails to consultants were frequently unread and unanswered, indicating a need for clear national or local guidelines on patient-clinician communication methods.
Noted (AI summary) Following the incident, the cardiomyopathy service now ensures that email correspondence with patients is added to the patient's health record. Trust-wide guidelines are being developed regarding email communication with patients. The Department of Health acknowledges the coroner's concerns, references existing GMC guidance on communication, and notes that Barts Health NHS Trust is addressing the issue. They state that concerns about individual clinicians should be raised with the GMC. The Trust is exploring current practice regarding email correspondence between clinicians and patients and will consider local guidance based on NHS England's Accessible Information Standard, pending national guidelines.
Lita Serkes
All Responded
2016-0458 16 Dec 2016 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial blood test results impacting treatment decisions.
Action Taken (AI summary) Barts Health NHS Trust has briefed medical staff on complete record-keeping, reiterated the availability of point-of-care tests, and is giving ongoing training to nursing staff in the use of PCA machines; a surgeon has been instructed to reflect on the incident at their next appraisal.
Margaret Tuck
All Responded
2016-0273 26 Jul 2016 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed investigation of confusion, contributing to undetected deterioration.
Action Taken (AI summary) Barts Health NHS Trust has re-instructed staff on falls risk assessments and care plans, clarified nursing responsibilities, reinforced post-falls procedures, and implemented measures to improve communication between medical teams. They have also addressed Datix reporting procedures for agency nurses.
Devinder Seth
All Responded
2016-0075 26 Feb 2016 London (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Ward staff lacked clear guidance on recognising and managing the risks and side effects of opiate medication in orthogeriatric patients, leading to unrecognised opiate toxicity.
Action Planned (AI summary) The Pharmacy department at Barts Health NHS Trust is producing guidance for staff relating to the risk of opiate medications, their side-effects and the signs of opiate toxicity, and a 'share the learning' bulletin. Newham University Hospital is planning to review Serious Untoward Incidents reported from 2013 to date to identify if there are any opiate related SUIs and is retraining all nursing staff.
David White
All Responded
2015-0437 11 Nov 2015 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate supervision was absent, and these notes were not reviewed or acted upon.
Action Taken (AI summary) Staff have been reminded of the importance of documenting allergies and adverse effects, including in Renal Mortality and Morbidity meetings; the safety briefing during nursing handover will now include care plans for patients at risk of falls, daily auditing of nursing documentation will be carried out, and Multidisciplinary Team meetings on Ward 9F have been changed to earlier in the day.
John Dack
All Responded
2015-0151 19 Feb 2015 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical administrative failures, specifically incorrect patient addresses in medical notes despite multiple notifications, led to missed follow-up appointments and have previously resulted in serious consequences.
Noted (AI summary) Barts Health NHS Trust investigated the incident and has reminded staff of the importance of accurately changing patient details and the consequences of not doing so. They note that the patient did know about the follow-up appointment.
Rufjan Bibi
All Responded
2015-0053 11 Feb 2015 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate nursing care for an incontinent patient, a nurse's suggestion of private care, and an unexplained five-hour delay for consultant review despite a critical GCS score were identified.
Action Taken (AI summary) The Trust implemented intentional rounding and documentation audits, and carries out observations of care. A doctor received training on obtaining consultant reviews, and the case was discussed at a morbidity and mortality meeting.
Awa Jeng
All Responded
2015-0015 20 Jan 2015 London (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures in monitoring, task handover, and medical review.
Action Taken (AI summary) The trust is implementing a revised early warning score system (NEWS and CREWS), has been awarded funding to implement a vital signs monitoring process (Vitalslink), has a full complement of middle grade doctors, holds regular mortality and morbidity meetings, sent instructions to junior doctors regarding trauma sheet completion, and discusses all renal dialysis patients with the renal team.
Andrew Aitken
All Responded
2014-0561 15 Dec 2014 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadequate management of patient's belongings and medication on admission, failure to seek crucial past psychiatric history, and poor discharge planning for a vulnerable patient without a GP.
Action Planned (AI summary) The Trust investigated the concerns, interviewing staff and reviewing medical records, finding that tablets left at the bedside were intended to be destroyed by a pharmacist and were locked in a medicine cupboard. The Trust booked and paid for a taxi to take the deceased home after discharge, as he had no clothes. The Trust will ensure staff are aware that patients can self-refer to the RAID service and is considering how to best communicate this information to all staff working in Tower Hamlets. The Trust will also ensure clinical discussions from daily clinical meetings are recorded in patient medical records and that junior doctors discuss patients seen during liaison duties in consultant supervision.
Irshad Ali
All Responded
2014-0387 29 Aug 2014 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The report identifies missing records of required nursing observations, a failure to complete neurological observations before discharge as stipulated, and miscommunication regarding physiotherapy assessment before discharge.
Action Taken (AI summary) The Trust has taken multiple actions including monthly nursing audits of patient note filing, reminders to nurses about discharge policies, and a review of processes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team, and the Senior Sister will be given a copy of the consultants' rota to facilitate nursing presence on ward rounds.
Gregg O’Reilly
All Responded
2014-0221 19 May 2014 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation records during a critical period before the deceased suffered a second bleed and cardiac arrest.
Action Planned (AI summary) Barts Health NHS Trust has concluded an investigation and outlined recommendations including recruiting a Band 7 Sister, shortening the transition to an electronic patient record, establishing a Critical Care Board (meeting August 2014), and launching an education strategy to identify deteriorating patients.
Bertha Cray
All Responded
2014-0037 24 Jan 2014 London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.
Action Taken (AI summary) The Trust has stopped using double-sided 'nil-by-mouth' signs with different instructions on each side, and will now issue signs with the same instruction on both sides. The family has been informed of the outcome of the investigation and seemed reassured by the changes made by the Trust.