Barts Health NHS Trust
NHS / Health Body
Action Taken
The trust is implementing a revised early warning score system (NEWS and CREWS), has been awarded funding to implement a vital signs monitoring process (Vitalslink), has a full complement of middle grade doctors, holds regular mortality and morbidity meetings, sent instructions to junior doctors regarding trauma sheet completion, and discusses all renal dialysis patients with the renal team. (AI summary)
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Dear Madam Inquest touching the death of Mrs Awa Jeng write in response to your Regulation 28: Report to Prevent Future Deaths, dated 20 January 2015. The investigation into your concerns regarding the fact that there was a lack of overnight edical review and insufficient nursing observations in the evening and night of 19 December 2013, and your concerns regarding the handover of responsibilities and tasks between and night shifts has now been concluded. I am satisfied that this investigation been sufficiently robust; in that we have scrutinised all relevant records and communicated with appropriate staff to inform our investigation. write to apprise you of the conclusions of the investigation. During the investigation, senior clinical staff involved were contacted and confirmed that the Trust is implementing a revised early warning score National Early Warning Score (NEWS) and Chronic Respiratory Warning Score (CREWS) which once implemented is expected to improve compliance with contacting and escalating assistance with deteriorating patients. This is implemented at Newham University Hospital imminently, as well as across the Trust' Newham University Hospital has been awarded funding to implement a vital signs monitoring Process known a5 Vitalslink which will transmit clinicam observationggto the Electronic Patient Record (EPR) by WI-FI and give real-time feedback to the cliniciae regarding at risk status and the appropriate action to take. This is currently piloted at Newham University Hospital with wider roll-out planned once the pilot is approved: floor, day has Early being being
Barts Health NHS] NHS Trust The Vitalslink system will enable remote observation and alert for patients at risk this can be used by the outreach team, ward managers and interested clinicians to rapidly detect patients even before the ward nurse has called in their concerns, It does not replace the paper records and is intended to provide an additional level of assurance. The use of a standard machine across the site will also contribute to a clearer training plan, there only one type of machine in common use_ During Stepping into the Future Programme (a pan-London NHS initiative to ensure that patient experience and safety is optimal) Newham University Hospital has refreshed the hospital at night meeting and work is under way to improve participation by all on-call teams at night to review and discuss patients flagged as at risk at the start of the shift; This includes the introduction of afternoon safety huddles which are open to all staff and disciplines where issues can be raised and resolved. For clarity; the changes described (above) also apply to Tayberry Ward. Mrs Jeng's death has been discussed at safety briefings on Tayberry Ward. The care and treatment of the deteriorating patient and the appropriate escalation of concerns is also a priority on the ward. Funding has been received for nursing staff to be trained to attain this specific skill set, at London Southbank University: There is a daily consultant led trauma meeting in which all admissions; referrals, patients awaiting trauma surgery, post operative patients from the previous and any sick patients under the care of the orthopaedic service are discussed, There is a formal list and documentation for this meeting, an action plan for each patient and a record is kept and recorded on the sheet This document forms the basis for the formal face-to-face handover meeting between the and night medical teams; Following your Report to Prevent Future Deaths, a section has been added for signing and dating the handover sheet between the member of the team involved and this sheet is retained in the orthopaedic department for audit and transparency purposes: The Trust acknowledges prior difficulties in the orthopaedic department at the time of Mrs Jeng's death;, due to shortages of senior staff due to ill health; a death, retirement and dependence on long term locum consultants. Since the beginning of 2014 four new substantive consultants have been appointed and further locum consultants with a plan to make these posts substantive. One of the new consultants has been appointed as the clinical governance lead for the department: There is better senior engagement with other departments on the Newham site and successful recruitment at the middle grade to stop the reliance on locum doctors, There is now a full complement of middle grade doctors At the SHO level the Trust continues to actively recruit although this remains a national problem: The Trust surgery Clinic Academic Group (CAG) is currently planning a potential international recruitment drive, which is under consideration by the surgery CAG executive director; being day day two
Barts Health NHS] NHS Trust Regular; formal, recorded Mortality and Morbidity meetings are held and issues are ranked on severity for their short or long-term harm and appropriate events trigger either a of Candour letter; further discussion, a Datix investigation or a Serious Incident investigation Instructions verbally and written have been sent to all junior doctors in orthopaedics and orthogeriatrics regarding their responsibilities to add details of any patient requiring review out of hours to the trauma sheet before finishing their shifts All renal dialysis patients admitted under surgical care are discussed with the renal team as a matter of course_ As each of the orthopaedic departments within the Trust has a different structure volume of work and varying information technology; these changes are local and not Trust wide. However;, similar measures are well established and very comprehensive at the Royal London Hospital site, and as a Trust; we are in regular contact with our colleagues at the other Trust sites, to share and Iearn from each others' practice. We have taken this as an opportunity to review our processes to enhance future care: The outcome of the investigation will be shared with all Trust medical and nursing staf;, to ensure that staff involved implement the above changes andraudit the adequacy and effectiveness of the changes. Thank you for bringirg your concerns to my attenticn. trust that you are assured have taken them seriously and investigated them appropriately:
Barts Health NHS] NHS Trust The Vitalslink system will enable remote observation and alert for patients at risk this can be used by the outreach team, ward managers and interested clinicians to rapidly detect patients even before the ward nurse has called in their concerns, It does not replace the paper records and is intended to provide an additional level of assurance. The use of a standard machine across the site will also contribute to a clearer training plan, there only one type of machine in common use_ During Stepping into the Future Programme (a pan-London NHS initiative to ensure that patient experience and safety is optimal) Newham University Hospital has refreshed the hospital at night meeting and work is under way to improve participation by all on-call teams at night to review and discuss patients flagged as at risk at the start of the shift; This includes the introduction of afternoon safety huddles which are open to all staff and disciplines where issues can be raised and resolved. For clarity; the changes described (above) also apply to Tayberry Ward. Mrs Jeng's death has been discussed at safety briefings on Tayberry Ward. The care and treatment of the deteriorating patient and the appropriate escalation of concerns is also a priority on the ward. Funding has been received for nursing staff to be trained to attain this specific skill set, at London Southbank University: There is a daily consultant led trauma meeting in which all admissions; referrals, patients awaiting trauma surgery, post operative patients from the previous and any sick patients under the care of the orthopaedic service are discussed, There is a formal list and documentation for this meeting, an action plan for each patient and a record is kept and recorded on the sheet This document forms the basis for the formal face-to-face handover meeting between the and night medical teams; Following your Report to Prevent Future Deaths, a section has been added for signing and dating the handover sheet between the member of the team involved and this sheet is retained in the orthopaedic department for audit and transparency purposes: The Trust acknowledges prior difficulties in the orthopaedic department at the time of Mrs Jeng's death;, due to shortages of senior staff due to ill health; a death, retirement and dependence on long term locum consultants. Since the beginning of 2014 four new substantive consultants have been appointed and further locum consultants with a plan to make these posts substantive. One of the new consultants has been appointed as the clinical governance lead for the department: There is better senior engagement with other departments on the Newham site and successful recruitment at the middle grade to stop the reliance on locum doctors, There is now a full complement of middle grade doctors At the SHO level the Trust continues to actively recruit although this remains a national problem: The Trust surgery Clinic Academic Group (CAG) is currently planning a potential international recruitment drive, which is under consideration by the surgery CAG executive director; being day day two
Barts Health NHS] NHS Trust Regular; formal, recorded Mortality and Morbidity meetings are held and issues are ranked on severity for their short or long-term harm and appropriate events trigger either a of Candour letter; further discussion, a Datix investigation or a Serious Incident investigation Instructions verbally and written have been sent to all junior doctors in orthopaedics and orthogeriatrics regarding their responsibilities to add details of any patient requiring review out of hours to the trauma sheet before finishing their shifts All renal dialysis patients admitted under surgical care are discussed with the renal team as a matter of course_ As each of the orthopaedic departments within the Trust has a different structure volume of work and varying information technology; these changes are local and not Trust wide. However;, similar measures are well established and very comprehensive at the Royal London Hospital site, and as a Trust; we are in regular contact with our colleagues at the other Trust sites, to share and Iearn from each others' practice. We have taken this as an opportunity to review our processes to enhance future care: The outcome of the investigation will be shared with all Trust medical and nursing staf;, to ensure that staff involved implement the above changes andraudit the adequacy and effectiveness of the changes. Thank you for bringirg your concerns to my attenticn. trust that you are assured have taken them seriously and investigated them appropriately: