Barts Health NHS Trust
NHS Trust
Action Taken
Barts Health NHS Trust has piloted a new process for reviewing Venous Blood Gas results, briefed staff on safety pauses, and implemented a vulnerable patient flag for learning disabled patients on electronic records. They are also developing a single GP referral line, internal professional standards with training, and increasing learning disability nurse capacity and training. (AI summary)
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Dear Mr Irvine
Re: Regulation 28 Report to Prevent Future Deaths
I write regarding your letter of 1 July 2022 regarding your concerns relating to the death of Daniel John Xavier 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. Venous Blood Gas (VBG) result not reviewed and therefore not acted upon prior to discharge
In response to this incident, the Emergency Department (ED) are piloting a new process for the management of VBG results. The process requires the person taking blood to take the result for sign off straight away and there is an allocated clinician who is dedicated solely to review VBGs, sign ECGs and take any resulting actions immediately. The effectiveness of this process and the additional resources required will be evaluated by October 2022 and developed using quality improvement methodology.
Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES
In the medium term, the department is examining whether VBGs can be tracked on the electronic patient records system in the same way as happens with ECGs. This would have the additional benefit of providing a more robust audit trail than paper and giving an immediate alert that a test had been completed.
Learning from the incident has been shared widely within the department, including at induction and at daily safety briefings. Furthermore, all staff have been briefed on the need for 3 pauses for safety, whereby checks are undertaken when the result is first available, then rechecked at the point of referral/movement to SDEC (Same Day Emergency Care) unit and then a further check at the point of discharge.
2. Chaotic referral from the patient’s GP to the surgical team
The Trust is working with senior colleagues from primary care to improve the system. Consideration is being given to introducing a single referral telephone line where calls are screened and accepted. We expect to have agreed a system by the end of October 2022. The principle will be that there is automatic acceptance of referrals from GPs.
The site is developing internal professional standards for speciality teams reviewing patients in the emergency department. This will include training on where to find all relevant information including tests carried out and GP consultation within the electronic patient records system. The expectation is to have these agreed by the end of October 2022
With regards to the internal processes within ED, it has been agreed that the clinician assessing the patient should document the immediate management plan (including tests and treatment) on the Cerner (electronic patient records system) record.
3. Due regard not given to the patient’s learning disability
Within ED, all patients with a learning disability will have the vulnerable patient flag applied to them on the electronic patient records system to raise awareness. As part of an SOP, all patients with a learning disability will be discussed with by a senior clinician (ST3 plus) as a minimum and prioritised for early review. The SOP is part of the induction package.
Across the hospital, all specialities will be asked to have learning disability (LD) training during their governance days this year. The hospital currently has a LD nurse on site 2 days a week and with future appointments will have one 4-5 days a week. There will be a LD section as part of statutory and mandatory training by the end of the year.
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.
Re: Regulation 28 Report to Prevent Future Deaths
I write regarding your letter of 1 July 2022 regarding your concerns relating to the death of Daniel John Xavier 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. Venous Blood Gas (VBG) result not reviewed and therefore not acted upon prior to discharge
In response to this incident, the Emergency Department (ED) are piloting a new process for the management of VBG results. The process requires the person taking blood to take the result for sign off straight away and there is an allocated clinician who is dedicated solely to review VBGs, sign ECGs and take any resulting actions immediately. The effectiveness of this process and the additional resources required will be evaluated by October 2022 and developed using quality improvement methodology.
Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES
In the medium term, the department is examining whether VBGs can be tracked on the electronic patient records system in the same way as happens with ECGs. This would have the additional benefit of providing a more robust audit trail than paper and giving an immediate alert that a test had been completed.
Learning from the incident has been shared widely within the department, including at induction and at daily safety briefings. Furthermore, all staff have been briefed on the need for 3 pauses for safety, whereby checks are undertaken when the result is first available, then rechecked at the point of referral/movement to SDEC (Same Day Emergency Care) unit and then a further check at the point of discharge.
2. Chaotic referral from the patient’s GP to the surgical team
The Trust is working with senior colleagues from primary care to improve the system. Consideration is being given to introducing a single referral telephone line where calls are screened and accepted. We expect to have agreed a system by the end of October 2022. The principle will be that there is automatic acceptance of referrals from GPs.
The site is developing internal professional standards for speciality teams reviewing patients in the emergency department. This will include training on where to find all relevant information including tests carried out and GP consultation within the electronic patient records system. The expectation is to have these agreed by the end of October 2022
With regards to the internal processes within ED, it has been agreed that the clinician assessing the patient should document the immediate management plan (including tests and treatment) on the Cerner (electronic patient records system) record.
3. Due regard not given to the patient’s learning disability
Within ED, all patients with a learning disability will have the vulnerable patient flag applied to them on the electronic patient records system to raise awareness. As part of an SOP, all patients with a learning disability will be discussed with by a senior clinician (ST3 plus) as a minimum and prioritised for early review. The SOP is part of the induction package.
Across the hospital, all specialities will be asked to have learning disability (LD) training during their governance days this year. The hospital currently has a LD nurse on site 2 days a week and with future appointments will have one 4-5 days a week. There will be a LD section as part of statutory and mandatory training by the end of the year.
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.