Barts Health NHS Trust
NHS / Health Body
Action Planned
The Trust is implementing a fully electronic outpatient outcome system and rolling out LUNA, a digital monitoring tool for patient tracking lists, expected by the end of September 2023. They have sought expert advice regarding limitations of the VTE risk assessment and will continue to monitor information from national bodies. (AI summary)
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Dear Mr Irvine Re: Regulation 28 Report to Prevent Future Deaths I write regarding your letter of regarding your concerns relating to the death of Christine Nakafeero at Newham University Hospital. I hope this letter will provide assurance to you of the steps that we are taking to address the concerns you have outlined. I will respond to these concerns in turn.
1. Patients lost to follow-up on the Gynaecology pathway We are implementing a fully electronic outpatient outcome system using outpatient organiser on our Cerner millennium system. This provides real time outcoming within clinics, and an electronic audit trail to track the patient along the pathway. Alongside the use of electronic outcome forms, the Trust is rolling out LUNA, a digital monitoring tool for patient tracking lists which will replace our current electronic waiting list tool at the end of September 2023. LUNA has the ability to pick up errors allowing staff to make corrections. It has an AI tool that reviews letters for key text which can indicate where incorrect discharge is matched with a letter stating the patient should be seen again. Therefore, this can be corrected, and a follow up appointment sent to the patient .
2. Limitations of the VTE risk assessment You raised concerns that the use of tranexamic acid and the presence of pelvic fibroids may have have limited the national risk assessment tool for prevention of venous thromboembolism although the national tool was used correctly.
The Trust has discussed this matter at the Venous Thromboembolism Prevention Committee and reviewed the available published evidence regarding the relative risk of these two factors and any other available guidance. Current evidence of relative risk is very limited and subject to debate nationally and there are no specific College or National guidelines available dealing with these specific topics. In addition, the Trust has sought advice from who is Professor of Thrombosis and Haemostasis at Kings College Hospital and Director of the National VTE Exemplar Centres Network in England as well as previously Clinical Lead for the National VTE Prevention Programme. The Trust has been advised that the use of the tool was appropriate and at this time there is not enough evidence to adapt or change this. In addition, in a patient who was experiencing recurrent heavy bleeding the use of enoxaparin was not indicated and there was no indication for anti-embolic stockings. The Trust’s VTE committee will continue to monitor the information received from national bodies as part of the overarching vigilance regarding preventable venous thromboembolism. Thank you for bringing your concerns to my attention. I trust that you are assured that I have taken them seriously and that the hospital has investigated them appropriately and is taking appropriate action. Please let me know if you require clarity on any of the points above.
1. Patients lost to follow-up on the Gynaecology pathway We are implementing a fully electronic outpatient outcome system using outpatient organiser on our Cerner millennium system. This provides real time outcoming within clinics, and an electronic audit trail to track the patient along the pathway. Alongside the use of electronic outcome forms, the Trust is rolling out LUNA, a digital monitoring tool for patient tracking lists which will replace our current electronic waiting list tool at the end of September 2023. LUNA has the ability to pick up errors allowing staff to make corrections. It has an AI tool that reviews letters for key text which can indicate where incorrect discharge is matched with a letter stating the patient should be seen again. Therefore, this can be corrected, and a follow up appointment sent to the patient .
2. Limitations of the VTE risk assessment You raised concerns that the use of tranexamic acid and the presence of pelvic fibroids may have have limited the national risk assessment tool for prevention of venous thromboembolism although the national tool was used correctly.
The Trust has discussed this matter at the Venous Thromboembolism Prevention Committee and reviewed the available published evidence regarding the relative risk of these two factors and any other available guidance. Current evidence of relative risk is very limited and subject to debate nationally and there are no specific College or National guidelines available dealing with these specific topics. In addition, the Trust has sought advice from who is Professor of Thrombosis and Haemostasis at Kings College Hospital and Director of the National VTE Exemplar Centres Network in England as well as previously Clinical Lead for the National VTE Prevention Programme. The Trust has been advised that the use of the tool was appropriate and at this time there is not enough evidence to adapt or change this. In addition, in a patient who was experiencing recurrent heavy bleeding the use of enoxaparin was not indicated and there was no indication for anti-embolic stockings. The Trust’s VTE committee will continue to monitor the information received from national bodies as part of the overarching vigilance regarding preventable venous thromboembolism. Thank you for bringing your concerns to my attention. I trust that you are assured that I have taken them seriously and that the hospital has investigated them appropriately and is taking appropriate action. Please let me know if you require clarity on any of the points above.