Margaret Tuck

Barts Health NHS Trust 
Trust Executive Offices 
Ground floor, Pathology Block 
The Royal London Hospital 
 London, E1 2ES 
Telephone: 020 32460632 
www.bartshealth.nhs.uk 

Ms Mary Elizabeth Hassell 
Senior Coroner for Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London 
N1C 4PP 

26 August 2016 

By Special Delivery 

Dear Ma’am, 

Inquest touching the death of Margaret Emily Tuck 

I write in response to a Regulation 28, Report to Prevent Future Deaths, dated 26 
July 2016, which was made at the conclusion of the inquest into the death of 
Margaret Emily Tuck. Barts Health NHS Trust takes Coronial investigations very 
seriously and I am sorry you have had to make Preventing Future Death 
recommendations and I am grateful to you for highlighting your concerns. 

The concerns you have raised in the Preventing Future Death report are: 

1. Although a falls risk assessment was conducted upon Margaret Tuck’s admission 
to hospital, when it demonstrated an increased risk of falling no falls prevention care 
plan was drafted.  

And, whilst most of the preventative measures that would have been detailed on 
such a care plan were implemented in any event, Mrs Tuck was described on the risk 
assessment as having no walking aids. In fact, she had a zimmer frame, and it was 
while reaching for this zimmer frame that she fell on the acute admissions unit.  

2. There was confusion about which nurse had primary responsibility for Margaret 
Tuck. Recourse was had to the bed diaries, but there was further discussion in court 
about whether the nurses had been sharing care. Such a lack of clarity seems 
undesirable.  

3. After her fall, Mrs Tuck was seen by a junior doctor who examined her thoroughly 
and filled in the medical portion of the post falls checklist. However, the nursing 
aspect of this form was never completed.  

The FY1 had wanted a neurological observation to be undertaken in addition to the 
protocol neurological observations of every 30 minutes, but her note was not wholly  

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 clear, and could have been interpreted as seeking only one neurological observation 
in total.  

In fact, no neurological observations at all were conducted on the day that Mrs Tuck 
fell, nor the day after.  

The FY1 doctor had wanted to speak to the primary nurse before leaving the 
bedside, but had been unable to find her. The twin nursing failures of documentation 
and observation might have been avoided if such a conversation had been 
mandatory, and there had been a simple way of achieving this. 

4. Mrs Tuck had been alert and orientated upon admission on 13 October, and 
remained so until the afternoon of 16 October, despite her persistently low sodium. 
When a haematology registrar found her to be confused however, an assumption 
was made that this confusion was the result of low sodium.  

It may be that this doctor was unaware of the falls and as a consequence did not 
consider the possibility that the confusion had been caused by a bleed, but this was 
the time when a CT scan was indicated.  

5. The consultant in charge of Mrs Tuck’s care did not learn of the 15 October fall 
until 17 October. It seems that the junior doctors on her ward did not bring this to her 
attention.  

Mrs Tuck’s nephew, however, was gravely concerned to find his auntie unable to 
communicate and brought this to the attention of the consultant. The consultant 
asked him “What do you want me to do, scan her brain?” and he replied “I think that 
would be a very good idea”. Hence a CT scan was conducted on the afternoon of 17 
October.  

6. I heard at inquest that agency nurses are unable to input into the trust reporting 
system (Datix). Bearing in mind that at times 50% of the ward staff are agency 
nurses, the matron who gave evidence suggested that agency nurses could be given 
a card similar to that given to locum doctors, so that they would not have to trouble 
their colleagues to help them make such reports.  

She was unsure whether this idea was going to be taken forward.  

7. The hospital investigation into the circumstances surrounding the death was 
conducted by a ward manager. The thinking behind having a senior nurse explore 
questions of nursing care is obvious. However, the report also commented on 
aspects of medical care that the report author freely admitted in court were outside 
her area of expertise. In terms of learning lessons for the future, this seems sub 
optimal.  

Clinicians giving evidence disagreed with some of the report’s conclusions, but I was 
not able to explore those areas with the true originator, because the views had come 
from a consultant who the author had consulted informally.  

The report was not recorded as being co-authored, and the doctor who had been 
asked for his view was not an oncologist. The author thought on reflection that an 
oncologist would have been better placed to comment on the medical management. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We have investigated the above concerns and I can confirm: 

The Hospital has undertaken a major piece of work to ensure vulnerable 

1. 
patients are identified and cared for, ensuring their risk of falling is minimised. A falls 
working group meets monthly, with each clinical area having to present their 
incidence of falls and work in progress around reduction of these incidents. On the 
AAU (representative of most clinical areas) all patients are assessed using the Trust 
falls assessment paperwork (which has been newly amalgamated into a nursing 
documentation admissions booklet), and any patient identified as a high risk, is then 
issued with a brightly coloured wrist band with the words ‘HIGH RISK OF FALLS’ 
printed on it. This signals to all staff, whether regular or agency, that this patient is at 
risk. All our high risk patients are now nursed within a bay that allows direct 
observation by nurses at the nurses’ station. There are plans for a Frail Elders Unit 
(FEU) in the near future, and this should allow better care of these highly vulnerable 
individuals. 

2. 
Since this incident the staff allocation has been revised, all patients admitted 
to the AAU now have a clearly identified, named nurse. Patients and their carers are 
made aware of this nurse on admission to the ward. All nurses on the unit, whether 
they are regular or agency nursing staff, will be made aware of the nurse in charge at 
the beginning of each shift.  In April 2016 we increased the number of senior sister 
charge nurse posts to increase the presence of senior nursing leadership across the 
24 hour period. This has led to far better leadership and care. 

Our Nurse Educator has been instrumental in setting up and delivering a new 

3. 
multi-disciplinary training programme around important issues, that includes falls 
prevention awareness and post falls care. As part of the Band 7 role regular 
assessment during the shift of care planned and delivered, is undertaken. All of our 
medical staff, including FY1’s, are invited to participate. Falls prevention and 
awareness is also included in the FY1 mandatory education programme. With the 
increased presence of Band 6 and 7 nurses on each shift all the clinical staff now 
have a first contact who they can handover important issues to, even when the 
named nurse is not on the ward. There are now four multidisciplinary board / 
handover meetings per 24-hours and these are focussed around patient safety and 
handover. This use of the named nurse and the increase in substantive fill rate, 
improves continuity of care and communication. 

and 5. There was breakdown in communication between the ward doctors, 

4. 
the Health Care of the Elderly (HCoE) team, and the Haematology team. These 
issues will be dealt with in one or more of our four daily handover meetings. 

As with all staff (medical, nursing and allied healthcare professionals), no-one 

6. 
needs a card of any description to log on and write a Datix. All our computers have 
generic log-ins that are given to all staff that need to access the computers and once 
logged in they can use the intranet to access the Datix system. The senior nurse on 
duty has been re-instructed to allow agency nurses to use their email address in the 
reporting system. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 All Serious Incidents and Morbidity and Mortality issues are discussed at our 

7. 
monthly and quarterly unit Governance meetings. All learning points are discussed 
and disseminated to all members of the AAU team, including all grades of nursing 
and medical staff. During the investigation the author of the report sought medical 
advice from the Clinical Director in Neurosciences. Both AAU and HCoE teams see 
such cases on a near daily basis, and are expert in dealing with the acutely unwell 
medical patient. We regret that miscommunication led to the delay in obtaining the 
relevant scan and believe the measures outlined will address such communication 
barriers.  

The hospital is adopting a process of round table discussions to investigate serious 
incidents. This will ensure that relevant expertise is obtained and the expert is named 
in the report. We regret that such expertise was not available to you first hand at the 
inquest and will in future ensure better representation from our clinical staff. 

I am once again grateful to you for bringing this case to my attention and I hope this 
letter fully answers the concerns you have raised. 

Yours faithfully 

Chief Medical Officer 
Barts Health NHS Trust