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.

Response Status (last 2 years, 6 reports)
Responded 3 No Response 3
AI Classification
Action Taken 71%
Action Planned 21%
Noted 7%
Disputed 0%
Based on 28 classified responses
PFD Reports Received by Quarter
Clear
PFD Reports
14 results
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.
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.
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.
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.
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.
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.
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.
Mary Bloom
All Responded
2015-0417 30 Oct 2015 East London
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Trust policy on heparin administration was not followed, including failure to weigh the patient, consult haematology, or take post-hydration bloods. Critical dosage advice for underweight patients was also easily missed due to poor visibility on posters.
Action Taken (AI summary) The trust implemented three new policies and a chart for unfractionated heparin administration. The guidelines now state that if the APTTR at 6hrs is outside the expected range then the Consultant Haematologist should be contacted for further advice in those patients at the extreme ends of the weight ranges i.e. <41kg and >90kg.