Barts Health NHS Trust
NHS / Health Body
Action Taken
Barts Health NHS Trust implemented a structured ward round template to improve communication and a teaching session on Nasogastric Tube Placement was delivered to teams on the wards. A comprehensive local induction pack was developed to ensure that all temporary workers have a robust induction to the clinical area. (AI summary)
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Dear Mr Irvine
Re: Regulation 28 Report to Prevent Future Deaths
I write regarding your letter of 12 November 2020 regarding your concerns relating to the death of Amarbai Bhudia at Newham University Hospital. I apologise for the length of time it has taken to get this response to you, which was due to the necessity to respond to immediate challenges brought about by the pandemic surge. 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. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant.
In response to concerns in the department of surgery regarding the quality and content of communications about clinical instructions, an audit was designed and implemented by the junior surgery team. This identified that there was a need for a structured ward round template, and showed that implementation of a structured ward round improved communication on the ward. This audit was accepted for presentation at The Royal College of Surgeons of Edinburgh, though the conference did not take place due to the pandemic.
2. Nursing staff had no clinical instruction as to how to manage the NG tube
A teaching session regarding Nasogastric Tube Placement was devised by the Barts Health Clinical Skills Facilitators and delivered to the teams on the wards by the Ward Managers and Professional Development nurse, and the slides used were shared by email with all staff. The teaching material included:
Information about responsibilities of staff. Indications for nasogastric tube insertion. Contraindications for nasogastric tube insertion. Information about high risk patients.
Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES
Telephone:
Chief Medical Officer
Complications associated with nasogastric tube insertion. An overview of National Patient Safety Agency (NPSA) guidance. Equipment required. NEX (nose to ear to xiphisternum) measurement. Head positioning during placement. Tube fixation. Insertion procedure. Confirming tube placement. Post procedure action. Subsequent testing. Use of a Ryles tube for drainage. Removal of nasogastric drainage tubes.
Furthermore, a new assurance template has been introduced to spot-check the presence of the nursing team on ward rounds. The medical plans are entered into a diary by the nurses to ensure the plans are communicated effectively. The Nurse in Charge checklist has now been introduced including clear guidance regarding the roles and responsibilities of the person coordinating the ward area.
We have introduced a Consultant Surgeon of the week model, with the same Consultant from Monday to Friday, and one for the weekend. This provides consistency and continuity of cover and helps to ensure good communication with all members of the multidisciplinary team; as the nursing team, nurse in charge and AHPs have a single point of contact for questions and escalation. This makes for better team working and safety culture.
The Trust’s nasogastric and orogastric policy has been revised, including the use of free drainage and regular aspiration (suctioning). The Trust Corporate Policy: Nasogastric/ orogastric tube policy (adults) was updated and approved on 24 July 2020 and includes information about the use of nasogastric tubes for drainage of stomach contents.
3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management
The Trust’s Induction Policy has been reviewed and revised (August 2020) to ensure that it includes assurances that temporary staff are competent to carry out the care and treatment of the patients they are allocated on the particular shift.
This policy included the Barts Health Local Induction Checklist for permanent staff and the Local Induction Checklist for temporary non-medical clinical staff (for use on all Barts Health sites). The booking system now records the specialist skills of temporary workers, both Bank and Agency, and prevents the booking of a temporary worker who does not possess skills identified on the booking request.
In order to ensure that all temporary workers have a robust induction to the clinical area, a comprehensive local induction pack has been developed and is provided by the Ward Manager to all new temporary workers.
Use of the induction pack ensures that the Nurse in Charge reviews the competency of the temporary worker to provide safe and effective care to the patient or patients they have been allocated prior to starting work, and allows learning to take place or for changes in the staffing allocation to be made to safeguard patients. When possible the clinical areas strive to use staff that have been assessed as competent in preference to a worker that is unfamiliar with the clinical area or the conditions encountered in the clinical area.
Since the incident the Ward Manager on East Ham Ward, has led on improving the knowledge and skills of the nursing workforce, and ensuring that the temporary workers allocated in Surgery meet the requirements of the service and are safe to practice.
4. Concerns regarding the NG tube function were not properly escalated to clinical staff
A local induction guide has been produced which clearly outlines what is expected of staff working on East Ham ward. Within it are multiple examples of the process of escalation, including the nursing staff being empowered to escalate to Consultants if not getting a response from junior doctors.
Thank you for bringing your concerns to my attention. I trust that you are assured that I have taken them seriously, 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 12 November 2020 regarding your concerns relating to the death of Amarbai Bhudia at Newham University Hospital. I apologise for the length of time it has taken to get this response to you, which was due to the necessity to respond to immediate challenges brought about by the pandemic surge. 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. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant.
In response to concerns in the department of surgery regarding the quality and content of communications about clinical instructions, an audit was designed and implemented by the junior surgery team. This identified that there was a need for a structured ward round template, and showed that implementation of a structured ward round improved communication on the ward. This audit was accepted for presentation at The Royal College of Surgeons of Edinburgh, though the conference did not take place due to the pandemic.
2. Nursing staff had no clinical instruction as to how to manage the NG tube
A teaching session regarding Nasogastric Tube Placement was devised by the Barts Health Clinical Skills Facilitators and delivered to the teams on the wards by the Ward Managers and Professional Development nurse, and the slides used were shared by email with all staff. The teaching material included:
Information about responsibilities of staff. Indications for nasogastric tube insertion. Contraindications for nasogastric tube insertion. Information about high risk patients.
Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES
Telephone:
Chief Medical Officer
Complications associated with nasogastric tube insertion. An overview of National Patient Safety Agency (NPSA) guidance. Equipment required. NEX (nose to ear to xiphisternum) measurement. Head positioning during placement. Tube fixation. Insertion procedure. Confirming tube placement. Post procedure action. Subsequent testing. Use of a Ryles tube for drainage. Removal of nasogastric drainage tubes.
Furthermore, a new assurance template has been introduced to spot-check the presence of the nursing team on ward rounds. The medical plans are entered into a diary by the nurses to ensure the plans are communicated effectively. The Nurse in Charge checklist has now been introduced including clear guidance regarding the roles and responsibilities of the person coordinating the ward area.
We have introduced a Consultant Surgeon of the week model, with the same Consultant from Monday to Friday, and one for the weekend. This provides consistency and continuity of cover and helps to ensure good communication with all members of the multidisciplinary team; as the nursing team, nurse in charge and AHPs have a single point of contact for questions and escalation. This makes for better team working and safety culture.
The Trust’s nasogastric and orogastric policy has been revised, including the use of free drainage and regular aspiration (suctioning). The Trust Corporate Policy: Nasogastric/ orogastric tube policy (adults) was updated and approved on 24 July 2020 and includes information about the use of nasogastric tubes for drainage of stomach contents.
3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management
The Trust’s Induction Policy has been reviewed and revised (August 2020) to ensure that it includes assurances that temporary staff are competent to carry out the care and treatment of the patients they are allocated on the particular shift.
This policy included the Barts Health Local Induction Checklist for permanent staff and the Local Induction Checklist for temporary non-medical clinical staff (for use on all Barts Health sites). The booking system now records the specialist skills of temporary workers, both Bank and Agency, and prevents the booking of a temporary worker who does not possess skills identified on the booking request.
In order to ensure that all temporary workers have a robust induction to the clinical area, a comprehensive local induction pack has been developed and is provided by the Ward Manager to all new temporary workers.
Use of the induction pack ensures that the Nurse in Charge reviews the competency of the temporary worker to provide safe and effective care to the patient or patients they have been allocated prior to starting work, and allows learning to take place or for changes in the staffing allocation to be made to safeguard patients. When possible the clinical areas strive to use staff that have been assessed as competent in preference to a worker that is unfamiliar with the clinical area or the conditions encountered in the clinical area.
Since the incident the Ward Manager on East Ham Ward, has led on improving the knowledge and skills of the nursing workforce, and ensuring that the temporary workers allocated in Surgery meet the requirements of the service and are safe to practice.
4. Concerns regarding the NG tube function were not properly escalated to clinical staff
A local induction guide has been produced which clearly outlines what is expected of staff working on East Ham ward. Within it are multiple examples of the process of escalation, including the nursing staff being empowered to escalate to Consultants if not getting a response from junior doctors.
Thank you for bringing your concerns to my attention. I trust that you are assured that I have taken them seriously, 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.