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.
PFD Reports
71 resultsCaliel 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.
William Bergman
Historic (No Identified Response)
2017-0343
31 Oct 2017
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A staff nurse prematurely dismissed a head injury as minor, failing to conduct vital observations or seek medical review for an elderly patient. This raises concerns that other healthcare professionals may similarly underestimate the severity of head injuries.
Errol Mann
Historic (No Identified Response)
2017-0128
20 Apr 2017
London (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care and diverted consultant time from clinical duties.
Nuala Seddon
Historic (No Identified Response)
2017-0034
6 Feb 2017
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The patient transfer decision may have been made by non-clinical staff and lacked documentation. Inadequate patient monitoring post-ITU discharge and a failure to properly investigate a patient arrest raised serious safety concerns.
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.
Catherine Dinnen
Historic (No Identified Response)
2016-0313
2 Sep 2016
London (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Concerns include significant delays in medical reviews, particularly out-of-hours, due to inadequate medical staffing levels. Lost observation records further hindered investigation into patient care.
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.
Zawdie Bascom
Historic (No Identified Response)
2016-0227
20 Jun 2016
London (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inadequate pain assessment and management in A&E, including missing pain scores on triage and after analgesia, led to unmitigated severe pain at discharge. Audit plans also failed to address general severe pain cases.
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.
Shalini Ganesh-Ram
Historic (No Identified Response)
2016-0117
22 Dec 2015
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies that a raised pulse, abdominal pain and lack of urine output did not prompt a CT scan and a surgical consult was not sought until four days post operation, suggesting suboptimal care due to issues within the system.
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.
Stephen Atherton
Historic (No Identified Response)
2014-0451
17 Oct 2014
London Inner (North)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his condition.
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.
Vijay Sonagara
Historic (No Identified Response)
2014-0364
7 Aug 2014
London (South Inner)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical medical information was not consolidated, as the patient had multiple unamalgamated records and a temporary file, leading to treating doctors being unaware of potentially relevant history.
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.