Barts Health NHS Trust
NHS / Health Body
Action Taken
Barts Health NHS Trust has displayed on-call doctor contact information in clinical areas, reviewed and updated the interaction between orthopaedic and orthogeriatric teams, and implemented a new escalation process for patients requiring medical assessment, with key actions completed and evidence to be presented to committees. (AI summary)
View full response
Dear Ms Persaud,
Thank you for your letter dated 15 December 2023 following the inquest of Mrs Margaret Ann Waylett, detailing concerns arising from the evidence presented and inviting the Trust to consider the implementation of changes to reduce the risk of future harm or death.
The Prevention of Future Death (PFD) report has been reviewed at the Whipps Cross Hospital Board and Divisional Boards to agree actions that will have an impact across the Barts Health group.
Your concerns and our response
1. Concern: The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review. A junior doctor described the junior orthopaedic staffing levels in the hospital as “dangerous”.
Response
• Staffing levels have been reviewed by the senior doctors in the divisions of medicine and surgery and are felt to be appropriate. Incidents are reviewed and feedback is listened to from junior doctors and taken into account when deciding on future staffing levels.
• Notwithstanding this, on occasions there are staffing gaps which can stretch the resource more than is intended. These risks are always mitigated as well as is possible and are regularly reviewed. Furthermore, plans to expand the Orthogeriatric Trust Headquarters Executive Offices Ground Floor
Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES
service are under consideration by the hospital with a vision to provide Orthogeriatric cover for all frailty fractures
• A new process has been introduced, in which contact information for on call doctors is displayed in relevant clinical areas so that there is complete clarity about who should be contacted.
2. Concern: The inquest heard that the NEWS charts were not available on the ward rounds. The consultants did not therefore review the charts and were unaware of the frequently raised NEWS scores. The inquest heard that laptops on the ward were unwieldy and time consuming. There were no iPads or vital packs available for the ward round team to easily access the NEWS scores.
Response
• The senior medical leadership team in the hospital have made it clear to all doctors in the service that regular review of NEWS data is part of professional standards. A review has confirmed that there is enough access to ensure that this happens in each clinical area.
• The above has been supported by laptop and iPad device availability which has been increased, with devices having been tested and confirmed as compatible with Cerner and functional for use. Computers on wheels are also available for use.
3. Concern: The inquest heard that there was confusion between the doctors as to who was responsible for the patient, in light of her dual orthopaedic and medical needs. Orthogeriatricians were aware of Mrs Waylett’s desaturation on 19 October 2022, but appeared to have considered it necessary for them to receive a referral from the orthopaedic team before they could carry out a review.
Response
• The interaction and interface between the orthopaedic and orthogeriatric teams has been reviewed and updated, to ensure that there is no misunderstanding and that no patient who would benefit from a medical assessment is missed. Junior doctors in both teams have clear and defined roles and responsibilities designed to ensure patients get the attention that is needed. Any patient under the care of the Orthopaedic team for who there is a clinical concern is escalated to either the On call medical team or the Critical Care Outreach team and intensive care for support and further management. Key actions in relation to the above are complete and evidence of completion will be presented at the Whipps Cross Quality and Safety Committee and to the Trust Quality Assurance Committee. The Trust deeply regret that the serious incident investigation report and associated action plan did not provide HM Coroner and the patient’s family with sufficient assurance around the actions implemented. Arrangements will be made to share this letter with the patient’s family and an offer extended to them to meet with senior clinicians to discuss any questions, concerns or
additional learning and improvement that the Trust should implement in light of the death Mrs Margaret Ann Waylett. If you have any queries, please do not hesitate to contact me.
Thank you for your letter dated 15 December 2023 following the inquest of Mrs Margaret Ann Waylett, detailing concerns arising from the evidence presented and inviting the Trust to consider the implementation of changes to reduce the risk of future harm or death.
The Prevention of Future Death (PFD) report has been reviewed at the Whipps Cross Hospital Board and Divisional Boards to agree actions that will have an impact across the Barts Health group.
Your concerns and our response
1. Concern: The inquest heard that nursing staff requested reviews by the on-call orthopaedic doctors on multiple occasions, without the doctors attending to carry out a review. A junior doctor described the junior orthopaedic staffing levels in the hospital as “dangerous”.
Response
• Staffing levels have been reviewed by the senior doctors in the divisions of medicine and surgery and are felt to be appropriate. Incidents are reviewed and feedback is listened to from junior doctors and taken into account when deciding on future staffing levels.
• Notwithstanding this, on occasions there are staffing gaps which can stretch the resource more than is intended. These risks are always mitigated as well as is possible and are regularly reviewed. Furthermore, plans to expand the Orthogeriatric Trust Headquarters Executive Offices Ground Floor
Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES
service are under consideration by the hospital with a vision to provide Orthogeriatric cover for all frailty fractures
• A new process has been introduced, in which contact information for on call doctors is displayed in relevant clinical areas so that there is complete clarity about who should be contacted.
2. Concern: The inquest heard that the NEWS charts were not available on the ward rounds. The consultants did not therefore review the charts and were unaware of the frequently raised NEWS scores. The inquest heard that laptops on the ward were unwieldy and time consuming. There were no iPads or vital packs available for the ward round team to easily access the NEWS scores.
Response
• The senior medical leadership team in the hospital have made it clear to all doctors in the service that regular review of NEWS data is part of professional standards. A review has confirmed that there is enough access to ensure that this happens in each clinical area.
• The above has been supported by laptop and iPad device availability which has been increased, with devices having been tested and confirmed as compatible with Cerner and functional for use. Computers on wheels are also available for use.
3. Concern: The inquest heard that there was confusion between the doctors as to who was responsible for the patient, in light of her dual orthopaedic and medical needs. Orthogeriatricians were aware of Mrs Waylett’s desaturation on 19 October 2022, but appeared to have considered it necessary for them to receive a referral from the orthopaedic team before they could carry out a review.
Response
• The interaction and interface between the orthopaedic and orthogeriatric teams has been reviewed and updated, to ensure that there is no misunderstanding and that no patient who would benefit from a medical assessment is missed. Junior doctors in both teams have clear and defined roles and responsibilities designed to ensure patients get the attention that is needed. Any patient under the care of the Orthopaedic team for who there is a clinical concern is escalated to either the On call medical team or the Critical Care Outreach team and intensive care for support and further management. Key actions in relation to the above are complete and evidence of completion will be presented at the Whipps Cross Quality and Safety Committee and to the Trust Quality Assurance Committee. The Trust deeply regret that the serious incident investigation report and associated action plan did not provide HM Coroner and the patient’s family with sufficient assurance around the actions implemented. Arrangements will be made to share this letter with the patient’s family and an offer extended to them to meet with senior clinicians to discuss any questions, concerns or
additional learning and improvement that the Trust should implement in light of the death Mrs Margaret Ann Waylett. If you have any queries, please do not hesitate to contact me.