Mohammad Asghar

Dear HM Coroner,

Thank you for your letter dated 29 September 2005 following the inquest of Mr Mohammed Ali Asghar. The Whipps Cross Executive team acknowledge that you provided the hospital with an opportunity to reflect on the decision not to commission a learning response and only issued a PFD when the Trust did not follow your express direction in the matter and submitted the rationale for this decision 3 months after the inquest.

The Prevention of Future Death report has been reviewed at Whipps Cross Divisional and Hospital Boards to agree actions that will have an impact across the Barts Health group. The PFD and response will be shared at Trust Safety Committee, with National Health Service England (NHSE), the Care Quality Commission (CQC) and the North East London Integrated Care Board.

Your concerns

1. A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Incident Response Framework. This omission gives rise to a concern that future deaths may follow due to an inability to on the part of the Trust to identify, reflect upon, and remediate sub-optimal practice, in this case the Trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.

2. Despite concerns being raised by a medical examiner, a coroner’s court finding that an iatrogenic injury was contributory to death, and an express direction from this court for the case to be reviewed, no patient safety framework investigation has occurred.

Trust Headquarters Executive Offices Ground Floor

Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES

3. Correspondence received from the Trust, sent three months after the inquest that seeks to explain why a PSIRF investigation was not undertaken in this case betrays the fact that senior governance staff at the Trust still do not understand NHS guidance on what should trigger a patient safety investigation.

Our response

We acknowledge the coroner’s concerns regarding the absence of a Patient Safety Incident Investigation (PSII) and the subsequent Prevention of Future Deaths (PFD) notice issued to the organisation. We recognise the importance of this feedback and are committed to ensuring that our governance and decision-making processes for identifying and commissioning investigations under the Patient Safety Incident Response Framework (PSIRF) are robust, transparent, and consistently applied.

While the governance process followed at the time reflected expert input and the information then available, we accept our assessment lacked necessary rigour leading to the decision of not requesting a PSIRF learning response. We acknowledge the need to strengthen our approach to ensure that decisions are informed by all relevant sources, including outputs from morbidity and mortality reviews, concerns raised by families/carers and the coroner.

To support this, Barts Health is in the process of commissioning an Independent Review of our governance processes with comprehensive terms of reference which will include review of our decision-making at Patient Safety Incident Review Meeting (PSIRM) relating to the learning responses under PSIRF. This review will examine the criteria and thresholds used to determine when a PSII or alternative learning response is required, ensuring these are clearly defined, consistently applied, and responsive to emerging information or stakeholder concerns.

The outcomes of this review will inform refinements to our local processes and provide additional assurance that lessons are identified and acted upon in a timely and proportionate way. We remain committed to a culture of openness, reflection, and continuous learning, and we will share the findings and actions arising from this review with relevant stakeholders, including the coroner.

If you have any queries, please do not hesitate to contact me.