Moses Boardman

Dear Mr Irvine, RE: Regulation 28 Prevention of Future Deaths Report: Moses Victor Boardman write in response to your Regulation 28: Report to Prevent Future Deaths, dated 11t August 2020, Your concerns are related to the discharge of Mr Boardman from the Royal London Hospital in December 2019 At the inquest you raised 6 matters of concern for Barts Health NHS Trust and Tower Hamlets Local Authority. The absence of clear computerised record in the RLH departure lounge explaining the change of address: This issue was identified as part of the trusts Serious Incident (SI) investigation and action was taken at the time: The departure lounge changed its practice to ensure that the staff document in the patients electronic record in line with trust practice_ Confirmation of this has been detailed within the departments most recent version of the Standard Operating Procedure (SOP): At the inquest you were shown this SOP in draft form but can update you now to say that it has now been signed off by the Royal London Hospital's Executive Board_ At the inquest you asked for evidence of this change in documentation and whether any audits had taken place. As an action in light of this query the departure lounge will now complete documentation audits in line with trust practice for clinical areas to provide assurance that this is completed. and being

NHS Barts Health NHS Trust
2. The lack of a clear safeguard to ensure that a vulnerable patient Is discharge to the correct address. Again, actlon was taken for thls concern at the time of the SI Investigation_ The departure lounge clarified in their SOP that when patient is discharged via hospital transport the Discharge Lounge staff will confirm with the Patient Transport Service driver the location and agreed destination for the patient: Any discrepancy must be escalated to the ward area for confirmation and Senior Clinical Site Manager if this discrepancy persists. Again, as per point 1, the staff will document this within the patients electronic medical records_ 3 The failure of RLH transport staff to properly assess the sultability of the venue that & patient Is belng taken to: The trusts transport team have safeguarding process for completlon when discharge destination raises concerns. At the time of the incident the process that the crews follow was similar t0 the rest of the Trust, they will raise both safeguarding ad adult care concerns using the safeguarding form which is then uploaded onto Datix (our risk management system for reporting adverse incidents) by an assistant manager However; if the crew member is on scene and is worried about heat, light, care package, or patient safety then they will call control to retum the patient to hospital. Direction is then taken from the ward, if are able to come back to the ward, then they take the patient there, if the ward has already allocated the bed to another patient; then the patient is taken back to the ED (Emergency Department): As an action the Associate Director of Transport has arranged to review the current safeguarding processes in place ad this process will be amended according to their findings: The responsiveness of the care provider commissioned by LBTH to escalate the fact that they had been unable to reach Mr Boardman for his first 3 visits This is a matter for LBTH to respond to The proper monitoring of patlents on RLH ward 14f who have been assessed as belng "fed at risk". Speclfically, why was a vulnerable patient left with unsuitable foods wlthln hls reach: The trusts clinical guidelines "Guidellnes for Best Practice: Eatlng and Drinking at Risk (Adults)" was approved in September 2019. This guideline was developed by Speech and Language Therapy and lays out the roles and responsibilities of the whole multidisciplinary team (MDT) In managing risk feeding in patients: The guideline contains a decision making tool as well as explaining the role and importance of patient preference and choice in the decision making alongside the MDT We have reviewed this document and recognise that It Is silent on the counselling of patients and their relatives as part of the process for managing their risk: As an action now we will review this guideline and make amendments to include details regarding this. they

NHS] Barts Health NHS Trust
6. The RLH failure to commence CPR when a potentlal reversible cause for collapse exlsted that would overrlde the effect of the DNAR order After the initial Serious Incident (SI) Investigation we understand there was concern about Mr Boardman choking on fruit, therefore a second investigation was carried out to look at this particular potential incident: It' s clear from staff statements that Mr Boardman had taken a bite out of the kiwi fruit before it was removed at 2000. At 0200 he is heard coughing and when the nurse attends she finds him unresponsive: Although he has a DNR order the cardiac arrest team is called. They arrive and find him unresponsive with agonal breathing: This type of breathing would not occur with any form of upper airway obstruction; it was also six hours after he had taken a blte of the kiwi frult This related to poor blood flow to the brain, fitting with the descriptlon of him having an impalpable pulse: In view of no immediate reversible cause, such as an airway obstruction the DNR order was followed and the gentleman passed away peacefully two hours later; Thank you for bringing your concerns to my attention: trust that you are assured that have taken them seriously and that the hospital has investigated them appropriately: am very happy to discuss or clarify any of the above points.