Barking, Havering and Redbridge University Hospitals NHS Trust
PFD Addressee
Reports: 31
Earliest: Sep 2013
Latest: 10 Mar 2026
50% 2-year response rate (below 83% average). 71% of classified responses show concrete action taken.
PFD Reports
31 resultsSheila Creegan
No Identified Response
2026-0147
10 Mar 2026
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust failed to conduct a proper patient safety investigation into the death despite clear errors, including an inaccurate initial cause of death and missed diagnoses of infection and heart failure.
Mohan Hothi
No Identified Response
2025-0513
14 Oct 2025
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust failed to investigate two serious unwitnessed falls, hindering its ability to identify and remediate suboptimal practices, with vague evidence of reflection and remediation.
Matthew Goldsmith
All Responded
2025-0499
9 Oct 2025
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Multiple significant abnormal findings in abdominal CT scans were repeatedly missed by radiologists, aggravated by the absence of a required peer review system for quality assurance at the Trust.
Action Taken
(AI summary)
Barking, Havering and Redbridge University Hospitals NHS Trust has implemented an action plan to address missed radiological findings, including mandatory training for radiologists, improved peer review processes, and use of discrepancy data to drive system improvement.
Chloe Every
All Responded
2024-0578
25 Oct 2024
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures in incident reporting and investigation.
Action Taken
(AI summary)
The Trust provides mandatory training for all staff including both nursing and medical staff related to the care of patients with a Learning Disability. In July 2024, the Learning Review Group was established and the Trust is monitoring implementation of the safety actions arising from learning responses via the Improvement Oversight Panel (IOP) which was implemented in July 2024. NHSE have informed the DHSC that BHRUT is preparing a response to address the coroner's concerns in full. Daily checks are conducted by the Learning Disability Team at the Emergency Departments and the wards for any learning disabilities, and governance processes have been updated.
Gordon Long
No Identified Response CC
2024-0503
19 Sep 2024
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust's patient safety investigation was inadequate, failing to explain a delayed vascular referral or identify responsible staff, undermining its effectiveness. No clear evidence of improvements from an agreed action plan was demonstrated.
David Morris
All Responded
2024-0360
4 Jul 2024
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Delays in cancer diagnosis and treatment were caused by poor organisation and communication. Staff failed to identify and escalate sepsis, clinical records were poor, and controlled drug management systems were ineffective.
Noted
(AI summary)
The Trust will not allow removal or deferral of cancer patients on a Patient Tracker List without consultant approval. A restructure of cancer administration pathways is underway and an external review of controlled medication practices is planned. The Trust has changed the process of Controlled Medication Keys and is trialing a digital key system and exploring installing CCTV. The MHRA acknowledges the concerns but states they cannot comment on medical advice or care quality. They explain the MHRA's role in assessing medical devices and note they received a previous NRLS report regarding a gastrostomy balloon device, but the investigation was closed in August 2023 due to the implementation of ENFit standards. The DHSC acknowledges the concerns regarding the care provided by the Trust and its processes. It outlines the roles of NHS England, CQC and MHRA and refers to NICE guidance and NIHR funded studies on sepsis.
Jennifer Whinney
All Responded
2023-0477
27 Nov 2023
Inner North London
Child Death
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of clear responsibility for ensuring their transfer, risking incomplete medical history.
Action Taken
(AI summary)
Barts Health NHS Trust has undertaken several actions to reduce line infections at the Royal London Hospital, including providing education and training sessions for multidisciplinary surgical staff, and updating IPC statutory and mandatory training. They are also in the process of re-writing the ANTT policy with the microbiology and Infection Prevent and Control (IPC) teams. Barking Havering and Redbridge University Hospitals NHS Trust has revised its policy for sending patient notes to external hospital visits, with the updated policy approved on 22 January 2024. The revised policy includes explicit responsibilities, a checklist, and a signature section for acknowledging receipt of notes.
Thomas Doyle
All Responded
2023-0397
20 Oct 2023
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The sepsis diagnostic pathway was repeatedly not commenced despite the patient meeting severe sepsis criteria, contravening Trust policy and delaying critical treatment.
Action Taken
(AI summary)
The Trust shared an internal alert with staff detailing good record keeping standards, developed a video explaining the importance of record keeping, and displayed a screen saver on Trust computers. They have also made significant improvements in sepsis screening in the Emergency Departments and now use an electronic record, Careflow. The Department of Health and Social Care notes the Trust has shared an internal alert and screen saver detailing good record keeping standards, developed a video explaining the importance of good record keeping, and discussed PFD concerns at meetings. Sepsis screening in the Emergency Departments has significantly improved.
Marion Luckraft
Historic (No Identified Response)
2023-0355
29 Sep 2023
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital sites, and an unclear treatment pathway for biliary sepsis collectively increased mortality risk.
Peter Harris
All Responded
2023-0260
20 Jul 2023
City of London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical scan results indicating malignancy were not promptly seen or acted upon by clinicians due to system failures in alerting and reporting delays caused by an incorrect hospital number.
Action Planned
(AI summary)
Barking, Havering and Redbridge University Hospitals NHS Trust will alert referrers to all imaging with expected, unexpected, or newly detected cancer, and critical non-cancer findings, with actions tracked in a version-controlled action plan. They will develop and implement a Standard Operating Procedure (SOP) for radiological findings of cancer, as well as a SOP for lung nodules identified as an incidental finding.
Matthew Phipps
Historic (No Identified Response)
2023-0219
29 Jun 2023
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The hospital lacked a contingency plan for providing intensive care when the unit was full, resulting in a patient requiring critical care not being admitted.
John Stiff
Partially Responded
2023-0120
18 Apr 2023
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Insufficient ortho-geriatric provision for elderly patients with hip and pelvic fractures, despite repeated requests, risks future deaths due to inadequate recognition and treatment of co-morbidities.
Action Planned
(AI summary)
The Department of Health and Social Care acknowledges the concerns regarding orthogeriatric provision and highlights the NHS Long Term Workforce Plan, which aims to double the number of medical school places in England by 2031/32 and increase generalist skills.
Maureen Dick
Historic (No Identified Response)
2023-0083Deceased
6 Mar 2023
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Medical staff exhibited a lack of professional curiosity and inadequate assessment of severe pain and a pressure ulcer, delaying diagnosis. There is also no mandatory training for clinical staff on pressure ulcers.
George Kearsey
All Responded
2023-0050Deceased
9 Feb 2023
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Inconsistent IV fluid administration, absence of fluid balance charts, poorly maintained records, and inadequate consultant review of fluid monitoring contributed to unsafe care.
Action Taken
(AI summary)
The Trust has conducted cross-site audits, shared fluid management guidance via the CMO newsletter, and produced training material on Careflow vitals, including a quick video for doctors. A clinical safety assessment is underway, with staff trained and a clinical safety officer being recruited. The Trust completed audits in Geriatrics and Frailty wards showing improvements in fluid chart completion, conducted random spot checks to ensure ongoing compliance, completed a Clinical Safety Assessment on Vital pack, and met with the family to resolve their concerns and invite them to share feedback with nursing staff.
Peter Ross
All Responded
2022-0354
4 Nov 2022
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A CT scan was misreported, and a reviewing surgeon failed to escalate a noticed abnormality. Repeated communication failures among clinical staff and poor record-keeping led to serious patient harm.
Action Taken
(AI summary)
Barking, Havering and Redbridge University Hospitals NHS Trust has taken multiple actions, including completing SI recommendations within Radiology, providing formal radiology training, sending reminders to staff regarding C-spine injury, developing better communication methods, and undertaking documentation audits. The Trust is currently in the process of implementing electronic patient record system. Barking, Havering & Redbridge NHS Trust presented the specific incident relating to Mr Ross at the Trust-wide Patient Safety Summit, delivered proposed teaching sessions for staff, made improvements to documentation, and audited the implementation of these improvements. The CQC will continue to engage with the Trust and part of the focus of this engagement will be the review of the improvements the Trust has made.
Graham White
Partially Responded
2022-0218
18 Jul 2022
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The Trust lacked a stent patient registry for monitoring and recall, couldn't assess risks to existing patients, and failed to escalate this death as a serious incident.
Action Planned
(AI summary)
The hospital implemented a new electronic stent register in August 2022 to track stents and warn staff of overdue stents. The Trust also retrospectively reviewed all stents inserted over the preceding 3 years and has started contacting patients who had been missed. The hospital has also introduced a lithotripsy service to reduce the need for stent insertion and has secured financial approval for a third Urology Consultant. The Trust has completed a Serious Incident/Root Cause Analysis and made recommendations, including providing patients with information leaflets and stent cards, establishing an electronic stent register, creating a standard operating procedure for stent management, investigating non-attendance, auditing patients with stents, assessing demand and capacity for treating stone patients, and strengthening incident reporting. BAUS acknowledges the need to log and track ureteric stents and improve patient/GP communication. BAUS will consider carrying out an audit of contemporary stent management practices and liaise with the Royal College of General Practitioners to discuss how information regarding stent symptoms and the importance of timely stent removal can best be disseminated to GPs.
Elizabeth Mills
All Responded
2022-0156
25 May 2022
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns
On 1 stApril 2021 this Court commenced an investigation into the death of Elizabeth Margaret Mills age 71 years. The investigation concluded at the end of the inquest held on the 12 th November 2021...
Action Taken
(AI summary)
The Trust has reviewed procedures, reminded staff to provide comprehensive notes of DNACPR discussions, and reinforced expectations for nursing patients receiving oxygen therapy. The checklist for patients in the Emergency Department has been upgraded to include a specific reference to investigations.
Louie Johnston
Historic (No Identified Response)
2021-0342
14 Oct 2021
East London
Child Death
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The CTG trace monitoring equipment required staff to switch screens during delivery, meaning a graphic representation was not continuously visible, and an obstetric registrar was not up to date with mandated annual CTG training, with systems not ensuring all medical staff completed requisite training.
Vivien Brunning
Partially Responded
2021-0340
12 Oct 2021
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported through the Trust's incident system.
Action Taken
(AI summary)
The practice held a meeting to discuss patient documentation workflow, agreeing that all DNA and Bardoc visit notifications will be date stamped and forwarded to the addressed GP; the amended policy will be updated by the practice manager and included in staff inductions.
Juliet Saunders
All Responded
2021-0157
18 May 2021
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Multiple failures included poor weekend ED support for learning disability patients, inadequate record-keeping, lack of junior doctor supervision, and repeated diagnostic overshadowing leading to missed acute conditions.
Action Taken
(AI summary)
The Learning Disability Team provides an advisory service to support clinical teams during the hours of 09:00 - 17:00, Monday to Friday and Safeguarding Oncall Manual has been created. The Trust commissioned an external thematic review in March 2021, into Serious Incidents {Sis) from the period of January 2019 to December 2020.
Stanley Babbs
All Responded
2020-0225
6 Nov 2020
East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Contrast media, a prescription-only medicine, was administered without a formal prescription, careful dose consideration, or a clearly identified responsible clinician, particularly for high-risk patients.
Action Taken
(AI summary)
The Trust has implemented several actions to improve the safe use of IV contrast in CT scans, including communicating a new IV Contrast protocol, emphasizing the importance of personalized evaluations for patients with eGFR less than 30, recording radiologist authorization decisions, providing specific training for radiographers and admin staff, and creating a new radiology request form to incorporate safeguards for patients with abnormal renal function.
Roger Wood
Historic (No Identified Response)
2020-0212
21 Oct 2020
East London
Community health care and emergency services related deaths
Concerns summary (AI summary)
A critical AAA scan result was not acted upon by the GP, and the updated referral policy still relies on GP action rather than direct automatic referral, risking similar failures.
Doris Clark
Historic (No Identified Response)
2019-0444
19 Dec 2019
London (East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A hospital doctor was unaware of morphine administered by paramedics due to inconsistent unit notation (mls vs. mgs), risking opiate overdose. Lack of standardised units between services creates a significant safety concern.
Sam Crick
All Responded
2017-0457
25 Aug 2017
Cambridgeshire and Peterborough
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Action Planned
(AI summary)
The Trust will review externally reported deaths weekly as part of a Morbidity and Mortality session to identify lessons and feedback to referring hospitals, as part of the ongoing SIR investigation. They have developed a 'Learning from Deaths' policy to respond to and learn from deaths of patients under their management. The CQC has requested written confirmation and evidence from Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) regarding actions taken following the death and any additional actions they intend to take. They are planning to inspect specific core services at BHRUT in the first part of 2018, including a 3-day in-depth inspection of the leadership and governance of the trust. NHS England will work with the Society of British Neurological Surgeons (SBNS) and the Royal College of Emergency Medicine to produce and distribute a guidance statement nationally within the next 6 months, focusing on treating patients with raised intracranial pressure and urging extreme caution in relation to the use of opiates. NHS England will also seek assurances from the Trust that they have addressed the concerns raised and will suggest an independent review of the case management.
Kevin Mann
All Responded
2017-0190
15 Jun 2017
London(East)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's failure to check prior imaging and an inadequate, unreviewed procedural policy.
Action Taken
(AI summary)
The Radiology Department audited Visipaque Swallows from May 2016-June 2017 and will conduct a further audit after the revised protocol is in use. The updated protocol recognizes the need for specific informed consent to be obtained from the patient.