Sheila Ridgway

Regulation 28:  Prevention of Future Deaths report 

Flora Marion BABER (died 22.02.18) 

THIS REPORT IS BEING SENT TO: 

1.  Professor Stephen Powis 

Medical Director 
Royal Free London NHS Trust 
Royal Free Hospital 
Pond Street 
London  NW3 2QG 

2. 

3. 

Registered Manager 
Compton Lodge Care Home 
7 Harley Road 
London  NW3 3BX 

Adelaide Medical Centre 
111 Adelaide Road 
London  NW3 3RY 

1 

CORONER 

I am:   Coroner ME Hassell 
           Senior Coroner  
           Inner North London 
           St Pancras Coroner’s Court 
           Camley Street 
           London  N1C 4PP 

2 

CORONER’S LEGAL POWERS 

I make this report under the Coroners and Justice Act 2009,  
paragraph 7, Schedule 5, and  
The Coroners (Investigations) Regulations 2013, 
regulations 28 and 29. 

3 

INVESTIGATION and INQUEST 

On 28 February 2018, one of my assistant coroners, Richard Ian Brittain, 
commenced an investigation into the death of Flora Marion Baber, aged 
92 years.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The investigation concluded at the end of the inquest yesterday. I made 
a determination that Flora Baber died from a combination of accidental 
falls and frailty of old age.   

I recorded a medical cause of death as follows. 
1a  aspiration pneumonia 
1b  traumatic left sided chronic subdural haematoma with re-bleeding 
2    thrombocytopenia, aortic valve disease, general frailty and dementia. 

4 

CIRCUMSTANCES OF THE DEATH 

Dr Baber was admitted to the Royal Free Hospital from Compton Lodge 
Care  Home  on  25  January  2018  with  increased  confusion,  slurred 
speech and difficulty in breathing.  She died there a month later. 

5 

CORONER’S CONCERNS 

During the course of the inquest, the evidence revealed matters giving 
rise to concern. In my opinion, there is a risk that future deaths will occur 
unless  action  is  taken.  In  the  circumstances,  it  is  my  statutory  duty  to 
report to you. 

The MATTERS OF CONCERN are as follows.  

Royal Free Hospital 

1.  Whilst  record  keeping  showed  Dr  Baber  as  having  been  given 
appropriate food and drink whilst on the ward in hospital, I heard 
that  sometimes  her  nearest  fluid  was  out  of  her  reach  on  a 
bedside table too far from the bed.   

Also, she did not always receive appropriately pureed food or the 
assistance that she needed to eat.   

2.  There  was  a  delay  in  referring  Dr  Baber  to  the  speech  and 

language team and in treating her oral thrush.   

Most significantly, I heard evidence that it was only when family 
members pointed out a problem such as pain on swallowing, that 
staff acted to deal with this. 

3.  Family members told me that at one point, they found the member 
of  staff  allocated  to  Dr  Baber’s  bay  sitting  in  a  chair  apparently 
asleep.   

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4.  Dr  Baber  was  noted  in  the  medical  records  as  being  doubly 
incontinent.  However, family members told me that she was not 
incontinent.   

Rather, when she asked for assistance to go to the toilet or to use 
a bedpan (she had poor mobility), a healthcare assistant told her 
that staff were busy, she was wearing an incontinence pad, and 
she should use that instead.   

I was shocked to hear this. 

Royal Free Hospital, Compton Lodge and Adelaide Medical Centre 

5.  Dr Baber had a sensitivity to opioids, such that her family noted a 
direct correlation between episodes of sickness and vomiting, and 
the administration of opioid medication.   

This had been recognised and recorded during earlier admissions 
to the Royal Free, and family had discussed with staff at the care 
home.   

However, it was not recorded as an alert on her hospital notes, or 
on her general practitioner notes, or on the care home notes.   

At  the  very  end  of  Dr  Baber’s  life,  the  benefit  of  pain  relief  was 
thought  to  outweigh  the  side  effects  of  opiates,  but  before  then 
her sensitivity was simply not recognised.   

This  caused  her  discomfort  and  distress,  and  in  another  case 
could have fatal consequences. 

6 

ACTION SHOULD BE TAKEN 

In  my  opinion,  action  should  be  taken  to  prevent  future  deaths  and  I 
believe that you have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date 
of this report, namely by 15 October 2018.  I, the coroner, may extend 
the period. 

Your  response  must  contain  details  of  action  taken  or proposed  to  be 
taken, setting out the timetable for action. Otherwise you must explain 
why no action is proposed. 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 8 

COPIES and PUBLICATION 

I have sent a copy of my report to the following. 

  HHJ Mark Lucraft QC, the Chief Coroner of England & Wales 
  Care Quality Commission for England  
 

, daughter of Flora Baber 

I  am  also  under  a  duty  to  send  the  Chief  Coroner  a  copy  of  your 
response.  

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he  believes  may  find  it  useful  or  of  interest.  You  may  make 
representations to me, the Senior Coroner, at the time of your response, 
about  the  release  or  the  publication  of  your  response  by  the  Chief 
Coroner. 

9 

DATE                                                  SIGNED BY SENIOR CORONER 

13.08.18 

4

Adelaide Medical Centre 
111 Adelaide Road 
London NW3 3RY 
Tel: 020 7722 4135 
Fax: 020 7586 7558 

 – Sessional GP 

Coroner ME Hassell – Senior Coroner  
Inner North London – St Pancras Corner’s Court 
Camley Street 
London  N1C 4PP 

Subject: Flora Marion BABER (died 22.02.18) 

Date:  26/09/2018 

Specifically Adelaide Medical Centre’s response to the recording of on GP notes a patient’s sensitivity 
to Opioids. 

Dear ME Hassell 

The main finding for the practice was that whilst an entry by 
that the patient could become confused/nauseous when taking opiates, no formal evidence of an 
allergy was recorded, only sensitivity was noted. In addition we needed to consider how this might 
have been better recorded in the notes, given that future use of an opioid may be in the patient’s best 
interest, as it was in the case for this patient. 

 in the patient notes highlighting 

In summary, our findings were that there is a way that sensitivities to opioid drugs could be recorded in 
the notes, however, this would be on a case by case basis.  There would remain a need for clinical 
judgement and only apply where the sensitivity was significant.  

The reminder of the letter outlines the actions and meetings we held. 

Actions: 

  18/09/2019:  Meeting 

, 

 (Managing partner) and 

 (Practice 

Manager); to discuss how the sensitivity to opioids could have been coded appropriately in the 
GP notes 

  18/09/2019:  Meeting 

 (Royal Free Geriatrician), 

Compton Lodge Dept Care Home Manager; To share Adelaide’s learning and see how this may 
support recording at the Royal Free and Compton Lodge. 

  25/09/2019:  Internal Significant Event at the Adelaide where details shared with all clinicians at 

the Adelaide. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
  
  
  
 
 
 
 
 
 
 
 Summary Detail of Meetings/Actions 

Detail:  18/09/2019:  Meeting 
Manager) 

 (Managing partner) and 

 (Practice 

  The notes of the pt were reviewed. 
  The entry by 

 on 31.10.2018, noted that pt could become confused/nauseous when 
taking opiates (buprenorphine).  However no evidence of a formal allergy was recorded, only a 
sensitivity/side effects was noted. 
It is therefore unclear what coding should be applied to patient notes in these circumstances.  
Coding as an allergy may prevent future use of an opioid when appropriate to do so.  This is 
recognised in the Coroner’s report. 

 

  On reflection, the sensitivity to opioids could have been recorded as a problem (Adverse 

reaction to drug) with relevant explanation (eg nausea and confusion).  This would then trigger 
a corresponding warning message when any opioid is prescribed.  However, this would be a 
judgement to be made by the clinician as many patients have a sensitivity to opioids, and this 
would only be done if the sensitivity is significant. 

  This reflection/learning has been captured in a significant event and shared with the other 

clinicians in the practice.   

The process a clinician could follow was demonstrated in the following screen prints: 

Screen print showing adding a problem (adverse reaction to drug) in EMIS with explanation: 

 
   
 
 
  
 Screen print showing alert that would then show when prescribing: 

Detail 18/09/2019:  Meeting
Compton Lodge Dept Care Home 

 (Royal Free Geriatrician), 

  Royal Free Hospital had already conducted their review of the Coroner’s report.  
 
 gave an overview the Royal Free meeting. 
  There was agreement with the Surgery that care is needed in recording sensitivity vs allergy 

where there was a potential downside of not using an opioid if needed in the  future  
  RFH felt it was not possible to consider a more systematic alerting of sensitivities/allergies 

between RFH to GP practice until the new IT system (planned for ~12mths) is implemented.  
Therefore, no process change to be considered at this time. 

25/09/2019:  Internal Significant Event at the Adelaide where details shared with all clinicians at the 
Adelaide. 

  The details of the case were shared with the clinical team at the practice. 
  Specifically discussed was the recording sensitivity to opioids as a problem with appropriate 
explanation that would allow an Alert to be automatically triggered whenever an opioid was 
prescribed. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 If we can support you Investigation in any further way, do let the practice know.  

Kind regards 

(Practice Manager) 

Managing Partner 

Patient’s Doctor

C&C

oF ac Iu) IG wide
aiion IM N cece
Compton Lodge i! 2018
7 Harley Road
London is wwe tent teten tt a
NW3 3BX

Coroner ME Hassell

Senior Coroner

Inner North London

St Pancras Coroner's Court
Camley Street

London N1C 4PP

Response to Regulation 28 Prevention of Future Deaths Report dated 13" August
2018.

RE: Flora Marion Baber (deceased 22/02/2018)

We are required to respond to the Coroner's concerns as regards the recording and sharing of
information between the Royal Free Hospital, Compton Lodge (owned by Central & Cecil
Housing Trust (C&C), and Adelaide Medical Centre in relation to Dr Baber's sensitivity to
opioids.

Diagnosis and recording of allergies to medication

It is important to clarify that if a resident develops an allergy to medication during their stay
with us, we would expect confirmation from their GP or hospital before making any amendment
to their care plan. Any information about a resident's allergy to medication would be advised in
hospital discharge notes, or by the doctors in the form of an official letter. When a resident
returns from hospital, a discharge letter should always be sent and a copy provided to the
resident's GP to ensure that their records and those of the pharmacist are updated. Any advice
concerning medication prescribed or any changes to such medication or dosage should also be
recorded on their MAR chart.

Any changes in the condition of the resident, including allergies, would also be noted on their
care plan by the Team Leader, being informed by the hospital discharge letter and / or advice
from the GP. Our residential Care Homes are not staffed by clinicians who are qualified to make
diagnoses of medication allergies or sensitivities. We rely wholly on the GP, treating doctors and
hospitals to communicate any medical changes and medication updates relevant to our
residents.

We understand the concerns raised by the family of Dr Baber in relation to her sensitivity to
opioids and in particular that they informed staff of their concerns in this regard, which were not
noted on Dr. Baber's care plan. We recognise that staff could have advised the family to discuss
their concerns with the GP, and in turn the Home could have requested further guidance from

the GP on how best to meet Dr Baber’s needs and what changes should be made, if any, to her
care and medication. Care staff could not rely upon advice from family members concerning
medication allergies and record this in Dr Baber's care plan however, without a supporting
clinical diagnosis and advice from a medical professional to do so. The doctors would need to
advise the Home through official communication (a letter) to ensure the MAR charts are updated
and the pharmacist is notified.

Upon receiving such information, the Home has a responsibility to ensure its own paperwork is
updated accurately. This would include both the MAR charts (updated by two senior members
of staff who have completed appropriate training), front covers to care plans and (if the
resident's medication includes controlled drugs), the Controlled Drugs (CD) book.

In order to improve the effective and accurate sharing of information concerning any changes to
residents’ medication (which would reveal any allergies or sensitivities), we recognise the
importance of ensuring the consistent recording and sharing of information between the Care
Home and the clinicians treating our residents. Following the death of Dr Baber and the
inquest, C&C has reviewed its practices associated with medication records and the sharing of
information with clinicians, across all of our Care Homes.

In order to drive forward improvements in this area, C&C has introduced a number of key
changes in the areas of management and accountability, record-keeping and the management
and disposal of medication. I have set out below a (non-exhaustive) summary of the relevant
procedures we have in place and an explanation of how the lessons learned following the death
of Dr Baber and the inquest, have led to substantive and lasting change not only at Compton
Lodge, but across all of C&C's Homes.

1. Medication administration and allergies: record-keeping
a) Policies and procedures:

i) All the documentation and information concerning the resident's needs and medication is
collated in the first instance from the resident's pre-assessment, which is completed in
conjunction with the resident and relatives prior to joining us. Any known medication
allergies at that time, would be noted on this form. This would then be confirmed by the
resident's GP and/or any treating doctors following hospital discharge, once the resident
has joined us.

ii) Any medication prescribed to a resident is listed on a Medication Administration Record
("MAR") chart when they join us. Again, any allergies would be noted and recorded on
the front cover sheet within the MAR charts if advised and confirmed by a medical
practitioner.

iii) Any changes to medication or discontinuation of a medication by a GP during their
clinical rounds at the Home must be documented on the MAR charts within the Home. It
should also be noted in the CD book. It is normal practice for the GP to be involved in
this process; however we recognise the importance of ensuring that the practice of
checking both the MAR and CD book concurrently, is imbedded in staff practice across all
of our Homes. C&C is committed to working on a close and practical level with our
residents’ GP’s to this end.

2

iv) The current process in place throughout our Homes for the disposal of discontinued
medication is for the pharmacist to collect it on at least a monthly basis. Where
medication is discontinued however, pending collection for disposal, we take immediate
steps to ensure that this is reflected on the resident's MAR chart (and the CD book if
relevant) and care plan. Discontinued medication is removed from the trolley in the
medication room, and placed in the clearly marked return box for collection by the
pharmacy. Any controlled drugs are kept in the controlled drugs secure cabinet, sealed
in a pocket envelope and clearly marked as discontinued.

v) Residents have Hospital Passports and Transfer/Discharge documentation in the event
that they need to attend hospital or are transferred to another Care Home. The Hospital
Passport allows for the recording of medical information, personal details, allergies,
previous medical history and the current care needs of the individual.

The Transfer/Discharge document also includes a body map, to be completed by the
Care Home staff on Discharge/Transfer and to include any skin issues such as rashes,
bruising, pressure sores, and medicinal patches. It also includes a current list of
medication, any infections present, allergies to medication, resuscitation status and the
resident's GP contact details.

vi) In our residential Care Homes, it is the responsibility of the Team Leaders to complete
the Discharge/Transfer forms, to ensure accuracy of the information provided, although
Home Managers have overall responsibility for all documentation completed and
maintained by the Home. Care plan documentation is reviewed on an ongoing (and at
least a monthly basis) and is amended if the relevant information for the individual
resident has changed.

vii) Staff best practice as regards reviewing and updating care plans is incorporated into care
staff job descriptions as a key requirement to fulfil their roles. Best practice is monitored
through regular one to one supervision meetings, and a comprehensive programme of
staff training is provided.

viii)To the extent that it is appropriate and in accordance with the resident's wishes, relatives
(next of kin) and / or Powers Of Attorney of each resident are given access to their care
plan, and they can request to read and provide input into all the care plan
documentation. A formal review of the care plans takes on an annual basis. Residents’
relatives are able to participate in this review and sign off on any revisions if they wish.

ix) We also have a Resident of the Day (ROD) system in place. During this monthly process
the care plans are reviewed by Team Leaders/Deputy Managers/Home Managers to
ensure they reflect the individual resident's current situation and needs.

b) Changes and improvements
i) To ensure that the correct documentation is sent with a resident on transfer, a check list
has been introduced for C&C Care Homes since the death of Dr Baber. This is to ensure

the person in charge has considered and included all the required documentation and
information about the resident's medical history and needs.

3

ii) Following Dr Baber's death, we have reviewed and tightened up medication recording
practices to ensure that when the MAR charts are updated, the CD book is also checked
and updated at the same time. We do this by ensuring that both the MAR charts and CD
book are both taken on the weekly GP rounds, and that both are then handed over to
the Manager, together with any notes made during the GP round, to be signed off. Staff
are also trained to ensure that they consult both the MAR charts and CD book
concurrently. The pharmacist is advised of any changes to a resident's MAR chart
through the normal monthly ordering cycle of medication through the resident's
prescriptions.

iil) Following issues with the consistency of collection of unused medication by Boots, we
have requested that all our home Managers across C&C Icok to engaging with a local
pharmacist to provide our medication. We have been consulting local GP's for their
recommendations in this regard, and a new pharmacist has already been appointed for
Compton Lodge. We believe that using local, recommended pharmacies will ensure that
we have a more complete service going forward, to include the more timely disposal of
medication and to initially include weekly audits, to support the Homes and provide
further staff training as required. As confidence grows within this new relationship, we
will move to external pharmacy audits on a monthly basis.

iv) C&C appointed a new Head of Care in September 2018. The Head of Care has completed
a review of all the documentation, policies and procedures used by C&C and the
induction process for care staff.

v) It is C&C's intention to introduce an electronic care plan system, which will prompt staff
to complete and update all relevant information in order to ensure that all questions are
considered. C&C are in talks with potential suppliers for this new system, and we intend
to introduce this, together with updating training for all staff tasked with reviewing and
updating care plans, in the first quarter of next year.

vi) In addition to daily, weekly and annual audits of care plan documentation, more focused
audits by the Quality and Compliance Manager have now been introduced to ensure that
the prescription of medications is recorded and any amendments updated as necessary.
This process is next due for review in December 2018.

vii) C&C have appointed a Clinical Services Manager who is nurse qualified and supports the
Homes with medication audits and provides support and training for staff in this area.

viiil)C&C have also appointed a new Director of Workplace and Culture who joined us in May
2018. She has been reviewing all the company policies and procedures and has been
working with the care team, including our Quality & Compliance Manager to review staff
our induction programme, including how care plans are reviewed and updated.

2. Staff training and supervision

a) Policies and procedures

i) C&C is continuing to implement the good practice required by and set out in the policies
and documentation currently in place, in addition to the further training being rolled out.

4

ii)

b)

ii)

iii)

ii)

iii)

C&C has daily, weekly and monthly audits that need to be completed both by staff within
the Homes and the Quality and Compliance Manager. All actions are then updated on a
Service Improvement Plan (SIP).

In order to keep best practice under review, all our staff throughout C&C have one to
one meetings with their line Managers, which are conducted every four to six weeks, to
ensure at least six take place per year. Within the Care Homes, the Manager will
conduct the one to ones with their administrator and the deputy Manager. The deputy
Manager conducts the Team Leaders’ one to ones. The Team Leaders then conduct the
carers’ one to ones. However in smaller Homes, the Home Manager will conduct any of
the one to ones throughout the Home especially if any concerns have been raised with
any of her team.

Changes and improvements

Since the incident at Compton Lodge, C&C have reviewed and increased the training
given to staff across all of its Homes, around care plan documentation and medication
administration, to ensure our residents’ safety. Further training focuses upon good
practice around recording and evidencing information about the residents' conditions and
needs, which is discussed and demonstrated in full. This has been developed as part of
staff refresher training, which is currently being rolled out throughout our Care Homes,
by our Quality and Compliance Manager. This should be completed by the end of this
year.

In addition to regular audits carried out by our Managers, C&C’s care planning and
medication administration system is now also monitored through additional, regular
audits carried out by our Quality and Compliance Manager.

Staff completion of the full induction programme is now checked and monitored more
robustly, to ensure that induction is completed within a strict timeframe and staff are not
able to commence working with residents until the full induction is complete. Induction
includes demonstrations for new staff on how care plan documentation is to be
completed and updated.

Since the new Home Manager at Compton Lodge was appointed in June 2018, more
rigorous checks have been put in place to ensure that the procedures for care plans and
medication records to be updated and maintained are followed consistently. The
storage of old care plan forms on local computers have been deleted to ensure that new
and relevant information only is added to the correct, up to date version of care plan
documentation for each resident. These improvements and checks have also been rolled
out across our other care Homes. Moving forward, this discipline will be closely
monitored by the Quality and Compliance Manager and continued improvements made
across all of C&C's Homes.

The development of further medication training is currently under review with our Quality
and Compliance Manager, the Clinical Services Manager and the Director of Workplace
Culture. The review is due to be completed within the next 3 months. Training already
includes a formal face to face training session with a comprehensive test at the end
which requires a 100% pass rate. This is in addition to the online training programme

5

provided by Boots, our pharmacists. If this training is not completed in full, then the
Team Leader or RGN are not able to administer medication within our Care Homes.

iv) This year we have introduced a monthly review of the SIP, which includes a meeting with
the Home Manager, Quality & Compliance Manager and the Operations Manager
dedicated to reviewing the progress of those service improvements detailed in the SIP
and to ensure that Managers are held accountable for their implementation. Actions can
only be closed down once the Quality & Compliance Manager has confirmed the action is
completed. This new process is already showing improvements in service quality
throughout the Care Homes in C&C. The identification and monitoring of these actions
has for example, resulted in the more efficient and timely rectification of issues, such as
cleaning requirements and has prompted staff to address any risks identified by
residents’ waterlow charts, on the same day.

v) We feel that previously the staff did not always have open and honest discussions
around new practices and the implementation of these policies. This is now regularly
discussed via group staff meetings and one to one supervision meetings within our
Homes.

vi) On 20 August 2018, the Home Manager at Compton Lodge held a meeting with care
staff to feed back the Coroner's key concerns and lessons learned. The importance of
maintaining good communication with residents’ families and GP’s was emphasised, and
staff were advised to value and record any key information or concerns raised by family
members concerning a resident's needs or care.

Valuable lessons have been learned in relation to the ways in which we communicate with GP's
and medical practitioners and update our own records concerning medication and allergies.
These have led to real changes in policy and staff training throughout C&C, and we recognise
the importance of continuing momentum in order to ensure that such changes become
established practice, embedded across our organisation and implemented effectively in all of our
Homes.

Yours sincerely

11th October 2018 

HM Coroner ME Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

Dear Ms Hassell, 

Response to Regulation 28 Prevention of Future Deaths Report – Dr Flora Baber 

I have set out within this letter the Trust’s responses to the Matters of Concern that you have 
brought to our attention in your Regulation 28 Prevention of Future Deaths Report dated 13 
August 2018.  I have been assisted in compiling the Trust’s responses by a number of 
colleagues, including: 

 
 
 
 
 
 
 

, Quality Governance Manager, Urgent Care. 

tin, Ward Manager, 8 West 

, Divisional Nurse Director, Medicine and Urgent Care; 

 Principal Pharmacist, Clinical Governance; 

 Adult Safeguarding Lead; 

 Group Head of Patient Systems; 
 Head of Quality Governance, Royal Free Hospital; 

I have set out below each of the matters of Concern, followed by the Trust’s responses. 

1.  Whilst record keeping showed Dr Baber as having been given appropriate food 
and drink whilst on the ward in hospital, I heard that sometimes her nearest 
fluid was out of her reach on a bedside table too far from the bed.  Also, she 
did not always receive appropriately pureed food or the assistance that she 
needed to eat. 

Following the Inquest, we wrote to the family to seek further information from them 
regarding all of the issues that they raised during the Inquest and particularly the 
Matters of Concern that you have raised.  The issues did not appear to have been 
raised by the family contemporaneously and unfortunately we have not yet received 
a response from the family to our request for further information so we have been 
unable to investigate any specific incidents as we would ordinarily wish to do and 
therefore the responses to the individual concerns are more generalised than we 
would ordinarily look to provide. 

The patient was cared for throughout her stay in 8 West in what is known as a “high 
bay”, meaning that staff were present in the bay at all times to supervise the patients.  
This bay is also visible from the main nursing station on ward 8 West.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Water is normally kept on the patients’ bedside tables and individual jugs are kept 
topped up throughout the day by domestic staff.  However, due to the patient’s 
subdural bleed, she was laid at a 30 degree angle throughout her final admission. 
Gold standard treatment and research concludes that the only position that has 
consistently shown to be acceptable is a head elevation of 30 degrees in patients 
following a brain injury. It would be expected that this would be an awkward position 
for any patient to be able to drink in, but the need to protect her safety in terms of the 
bleed was considered to be paramount. If the patient was attempting to obtain a drink 
and could not manage to reach it, it is expected that this would be seen and rectified 
by the staff member supervising the ward.  There is evidence within the patient’s 
notes of hourly rounding being done which means that Nursing Assistants specifically 
attended to the patient every hour to check that she was comfortable.  Part of the 
rounding protocol is to offer patients a drink each time they are visited by the Nursing 
Assistant.    

In addition, the Ward Manager conducts ward rounds three times per day.  During 
these he visits all areas, starting with the high bays.  As part of his checks he 
ensures that patients’ tables are within reach when appropriate, and that they have 
glasses of water on them. 

The patient was given a pureed diet from 13 February 2018 when it was 
recommended by the Speech and Language therapist following their assessment. Up 
until this point, the patient had been on a soft food diet and as already stated in your 
PFD Report, the food and fluid intake charts indicate that the patient was eating this.  
A soft diet consists of food such as mash, soup, custard, sauce, etc.  The patient was 
also prescribed and administered Ensure, a nutrition supplement, from 31 January 
2018.  When patients are prescribed specific diets, this is included on the SBAR 
(daily handover sheet) so that all staff are aware on a daily basis.  

This food is prepared by the kitchens and sent up to the wards.  When it arrives on 
the ward, either a nurse or a HCA checks the food.  If it was not deemed to be 
appropriate, it would be sent back to the kitchen and a replacement requested.  This 
patient was on a “red tray”, meaning that this flagged as a reminder to all staff that 
she needed assistance with eating.  Either a nurse or a healthcare assistant (HCA) 
would bring the food to the patient and they were then responsible for staying with 
her to help her to eat, unless a family member was there who wanted to do it instead.  
Sometimes meals needed to be staggered depending on the number of patients who 
needed assistance at any one time. 

We would be very concerned if any of our patients were not able to access their food 
and drink, as has been suggested in this case.   As you have observed, the patient’s 
fluid balance chart shows that she was given adequate hydration.  Her blood results 
do not indicate any dehydration, apart from one slightly raised sodium level on 2 
February 2018.  

In response to your concerns, all issues raised by this case have been discussed 
with staff on Ward 8 West at the staff morning meetings, specifically on Tuesday 14 
August 2018, the day after the Inquest, but also periodically since then.  They have 
been reminded to ensure that patients’ tables are within reach where safe to do so, 
and to pay particular attention to hydration needs and call bells. 

Please note that the Trust’s Head of Patient Experience arranges annual “place 
visits” in which patient representatives visit wards to observe and audit various 
practices.  Part of this involves looking at whether patients have water and if their 
hospital tables are prepared ready for food to be delivered.  If a patient is on a red 

2 

 
 
 
 
 
 
  
 
 tray, they follow the tray from arrival on the ward until the patient is eating to ensure 
that appropriate assistance is given.  The last round of place visits were conducted in 
March 2018 and no concerns were raised. 

In order to assure ourselves further, two independent unannounced spot checks 
within the next month will be undertaken to evaluate whether patients are being given 
appropriate food and the necessary assistance to eat.  We will also assess that fluids 
are in reach where appropriate and whether assistance is given if required. 

Furthermore the clinical practice educator will include nutrition, safe swallow, 
continence care, and assistance with toileting in the HCA study days, which will be a 
rolling programme of education.  She will also discuss this case at the study days as 
an opportunity to raise awareness of the patient experience.  Finally, our hospital 
quality governance manager will present the learning from this case at the next 
Health Services for Elderly People specialty governance meeting. 

2.  There was a delay in referring Dr Baber to the Speech and Language Team and 
in treating her oral thrush.  Most significantly, I heard evidence that it was only 
when family members pointed out a problem such as pain on swallowing, that 
staff acted to deal with this. 

The patient was admitted to the Royal Free Hospital on 25.01.2018.  The HSEP SpR 
responsible for the patient recalls that the patient’s daughter raised a concern about 
poor oral intake on 30.01.2018.  The patient’s intake chart showed that she had 
eaten three quarters of her porridge, as well as all of her soup and custard so far that 
day, so the medical team did not feel that there was any evidence of painful 
swallowing at that point (which may have been an indication of the possibility of 
thrush). 

There are daily multi-disciplinary board rounds on the ward.  These are attended by 
the medical team, nursing staff, physiotherapists, occupational therapists, social 
services and dietician (on Mondays and Thursdays), psychologist (when required), 
and, particularly, speech and language therapists (SALT) (daily Monday to Friday).  
All patients on the ward are discussed at every board round, the results of which are 
documented in the medical notes so that all staff involved in the patient’s care have 
an opportunity to raise any concerns, including any that may have been 
communicated by the family.  It is expected that if staff had any concerns about the 
patient’s swallowing ability at any point during her admission this would have been 
discussed with the multi-disciplinary team and action taken accordingly.    

There is an entry from a member of the nursing staff on Saturday 03 February 2018 
to say that the patient’s daughter felt that the patient had trouble swallowing, which 
had been passed onto the Nurse in Charge and that the patient would be reviewed 
by the Speech & Language team (SALT).  A further entry was made by nursing staff 
on Sunday 04 February 2018 in which they note that the patient appeared to have 
pain when swallowing and so they had escalated their concerns to the doctor.   

The patient was seen by a doctor on Sunday 4 February but the focus appears to 
have been on possible discharge planning.  There is no reference to swallowing 
issues in this entry.   

            However, the Nystatin to treat oral thrush was prescribed on Monday 05.02.2018  
            this would indicate a two day delay.  However, we are aware that the family 
            believe that the delay was longer (5 days) and 
            the patient’s family about this.   

 has already apologised to  

3 

 
 
 
 
 
 
 
 
 
 
 The SpR Doctor who prescribed the Nystatin recalls the patient’s oral thrush being 
mild at that time, which was communicated to a Camden Social Services 
safeguarding investigation meeting held on 15 June 2018.  The outcome of that 
investigation was that Camden Social Services felt that no further action was 
required.   

However, 
and treatment with all medical staff on the ward. 

 has agreed to share the learning regarding thrush recognition 

There is a further entry on Monday 5 February 2018 in which nursing staff have 
noted that although the patient did not have any complaint of pain in her mouth on 
that day, she was given mouth care and encouraged to increase her oral intake, 
following SALT guidance.  Although there is no documentation in the patient’s notes 
from SALT at this time, this entry would suggest that the patient was at least 
discussed with them. 

When the patient was noted to be coughing when given fluids on Monday 12 
February 2018, the patient was appropriately referred to SALT.  Staff were 
concerned about the risk of aspiration.  SALT came to review the patient the 
following day (13.02.18) and noted that assessment was limited due to the patient’s 
drowsiness and lack of capacity.  They felt that she was a high risk of aspiration and 
recommended that she should only be given teaspoons of water and only 2 – 3 
teaspoons of puree at a time.  They also advised that consideration should be given 
to making the patient nil by mouth if concerns continued.   

In conclusion the Trust apologises for any delay in initiating treatment for oral thrush, 
but we cannot find any evidence that there was a delay in referring the patient to 
SALT.  As mentioned previously, all issues raised by this case have been discussed 
with staff on Ward 8 West at the staff morning meetings, specifically on Tuesday 14 
August 2018, the day after the Inquest, but also periodically since then. 

As previously mentioned, in order to assure ourselves further the clinical practice 
educator will include nutrition, safe swallow, continence care, and assistance with 
toileting in the HCA study days, which will be a rolling programme of education.  She 
will also discuss this case at the study days as an opportunity to raise awareness of 
the patient experience.  Finally, our hospital quality governance manager will present 
the learning from this case at the next Health Services for Elderly People specialty 
governance meeting. 

3.  Family members told me that at one point, they found the member of staff 

allocated to Dr Baber’s bay sitting in a chair apparently asleep.  

There is no record of the patient’s family reporting this at the time.  Such an 
allegation causes us great concern.  If a situation like this were to occur, this would 
be completely unacceptable and contrary to Trust values and professional standards. 
The Ward Manager recalls the family stating during the inquest that this incident 
happened on a Saturday at about lunchtime.  As stated above, a letter was sent to 
the family after the inquest to ask them to provide further details of the alleged 
incident but we have not yet received a response so again, we are only able to 
comment upon this in general terms.   

8 West’s Ward Manager has reviewed all the staff rotas for the Saturdays during this 
patient’s admission and has spoken to all staff on shift.  They all deny being asleep 
or being aware of a colleague sleeping. 

4 

 
 
 
 
 
 
 
 
 
 
 
 Some patients in the same bay would have had capacity.  There were no reports, or 
concerns raised, from them, their visitors, or other staff members about a staff 
member sleeping at any time.  On a Saturday lunchtime there would be domestic 
staff, visitors, doctors, and nurses in and out of the bay regularly.  Ward 8 West does 
not have any visiting restrictions so visitors can attend the ward at any time.  They 
report that typically the weekends are very busy with visitors, especially around the 
lunchtime period.  The Nurse in Charge also conducts regular walk rounds on every 
shift.  Furthermore, as previously mentioned the enhanced bay in which the patient 
was situated is immediately in front of the nursing station and highly visible. 

A search has been conducted on the Trust’s Datix system which has shown that 
there have been no other incidents reported of staff members sleeping on duty on 
Ward 8 West at any time.  

Staff shifts are normally organised so that nurses and healthcare assistants work for 
two to three days in a row and then have two days off.  Staff rest breaks are 
organised and published on a board at the beginning of each shift.  There is not a 
culture on the ward of staff missing breaks.  As mentioned above, the Ward Manager 
has checked the staff rotas for this time period and has not seen any evidence of 
staff working excessive hours to suggest that they may have been particularly tired at 
this time.   

Staff who supervise bays are doing this duty for 10hrs and 45minutes per shift.  They 
are provided with a chair within the bay as it is recognised that this is a long time to 
be standing.  However it is expected that they will not have prolonged opportunities 
to sit during these shifts as the patients in a high bay are high acuity and need a lot 
of interaction from staff.  Nevertheless staff have been reminded that when 
supervising bays they should be interacting with patients where appropriate, rather 
than sitting for long periods of time.  

All Healthcare Assistants (HCAs) and most of the senior nurses on Ward 8 West 
have undertaken CAPER training.  HCAs generally provide the enhanced 
supervision for patients that need it. CAPER training includes specific guidance for 
interacting with patients, particularly those with dementia.   

I would like to assure you that the Divisional Management Team conduct regular 
leadership rounds to clinical areas, which are carried out at least monthly.  Some of 
these are unannounced.  The Executive Team also plan to start walk rounds in the 
near future and these form part of a pre-existing overarching quality governance 
action plan within the hospital. 

4.  Dr Baber was noted in the medical records as being doubly incontinent.  

However, family members told me that she was not incontinent.  Rather, when 
she asked for assistance to go to the toilet or to use a bedpan (she had poor 
mobility), a healthcare assistant told her that staff were busy, she was wearing 
an incontinence pad, and she should use that instead.  

Ward 8 West staff report that the patient was generally doubly incontinent throughout 
her stay, although they report that she had moments of lucidity when she sometimes 
asked to use the toilet.  

This allegation was not raised by the family members during the patient’s admission 
as far as we are aware, and no further information has been provided since, as 
indicated above, so that any staff member involved could potentially be identified.  

5 

 
 
 
 
 
 
 
 
 
 
 
 The Ward Manager has spoken to all staff on the ward, none of whom recall this 
happening. 

However, if this did happen to any patient it is completely unacceptable, as the Trust 
strives to maintain patients’ dignity at all times and it would certainly be more 
dignified to offer patients the opportunity to use a bedpan, rather than incontinence 
pads, if requested.  

As the patient had been admitted with a subdural bleed, along with confusion, 
delirium, agitation, and visual hallucinations, it was not considered safe to encourage 
her to stand.  The patient was assessed as being at a very high risk of falls.  She was 
nursed in bed throughout her admission and was normally very confused.  It was not 
felt that it would have been appropriate to assist her to a toilet, both for her own 
safety and for staff in terms of manual handling.  However, a bed pan could have 
been an option.  Due to the patient’s confusion, it was not felt to be appropriate to 
rely on her being able to call for staff when she needed the toilet, and there are no 
records of her regularly asking for a bedpan, so it was considered most appropriate 
to give her incontinence pads.   

All the concerns raised have formed part of a Safeguarding Conference where this 
allegation was discussed. The ward manager was questioned by Camden Local 
Authority on the possibility of this occurring and asked to evidence what processes 
were in place and what actions were now in hand to ensure that all measures are 
taken to assist patients to maintain their dignity and afford the opportunity to not use 
incontinence pads where possible.   

All HCAs on Ward 8 West are working towards completion of a care certificate, which 
includes continence care.   

As previously mentioned, all staff on Ward 8 West have been reminded on Tuesday 
14 August 2018 and on other dates since then, that even if patients are incontinent, 
they should be assisted to use the commode or a toilet if they request, and if it is safe 
to do so.   Further assurance will be sought via actions 2, 3 and 5 on the attached 
action plan. 

5.  Dr Baber had sensitivity to opioids, such that her family noted a direct 

correlation between episodes of sickness and vomiting, and the administration 
of opioid medication.  This had been recognised and recorded during earlier 
admissions to the Royal Free, and family had discussed with staff at the care 
home.  However, it was not recorded as an alert on her hospital noted.  At the 
very end of Dr Baber’s life, the benefit of pain relief was thought to outweigh 
the side effects of opiates, but before then her sensitivity was simply not 
recognised.  This caused her discomfort and distress, and in another case 
could have fatal consequences.  

It is noted that the family reported that the patient had sensitivity to opioids and 
preferred not to take them as she did not like the side effects.  Although not strictly 
an allergy, this sensitivity (opiates and Cephalexin) was noted on the patient’s 
discharge summary as such on 09 January 2018 which was sent to the patient’s GP.  
An earlier sensitivity to Fentanyl had been notes on her discharge summary of 2016.  
It is understood that the GP surgery have confirmed receipt of these documents.  It is 
regrettable that there is no robust system in place to ensure that allergy/sensitives 
are recorded and shared at all times.  This was reported as an incident on the Trust 
datix system prior to the Inquest, following concerns raised by the patient’s family. 

6 

 
 
 
 
 
 
 
 
 
 Discharge summaries/ TTAs are generated on Freenet (the local Trust intranet).  The 
TTA form provides the discharge summary and the list of medications that the patient 
is being discharged with. 

On admission via the Emergency Department, doctors use the RFH electronic 
system Power Chart on Cerner, to input patient information.  They currently do not 
record allergies on this system.  However this system has the ability to record blood 
results and these are then automatically pulled onto the discharge summary on 
Freenet.   

Currently, allergies and sensitivities are documented manually on the Freenet TTA 
form and on drug charts by doctors.  They can also be amended/added by 
Pharmacists.   Currently, allergy and sensitivity information must be manually 
updated each time a patient is discharged. 

Learning from this incident has already been shared with Pharmacy staff as well as 
at junior doctor prescribing teaching sessions to remind them all that allergies and 
sensitivities must be recorded and checked on each admission and discharge. The 
action to mitigate recurrence is to ensure that all staff are reminded about the need to 
manually record allergies/sensitives on the Freenet TTA form and drug charts 

As a short term solution pharmacy are exploring the option with IT/Cerner to assess 
the best possible way to record allergies and transfer them from the point of 
admission (recording of allergy status on Cerner) to the automated pull of this data to 
the Freenet TTA. We would like to continue the current option of manual amendment 
of the allergy status on the Freenet TTA (as this can change through the patient’s 
stay in the hospital).   We hope that Doctors, nurses, and pharmacists will be allowed 
the option to amend the allergy status in Freenet and Power chart on Cerner.   There 
are a number of separate sets of programming codes for different templates required 
to implement these changes so this will take some time to embed, but the IT 
department have begun working on this.  They are also exploring the feasibility of 
backdating allergy information for patients who have already been seen within the 
hospital.  

In the long term, once EPR/ EPMA (electronic prescribing system) is introduced in 
the trust this will automatically populate the TTA/discharge summary with the allergy 
status of the patient from the electronic prescription.  It is expected that this will go 
live at Barnet and Chase Farm by the end of this year, and will be rolled out across 
the Royal Free site in 2019.  There will be prompts on this system to alert staff when 
an allergy has not been recorded, and it will be more easily auditable than the current 
system.    

ADDITIONAL INFORMATION 

As you are aware, on arrival at the Royal Free Hospital on the 25th of January 2018 a 
Butrans patch was found on the patient’s skin. The staff in Compton Lodge agreed to 
investigate how this happened and a Safeguarding Alert was completed externally in 
the community by the home. This was confirmed by the hospital staff on the ward. 
The hospital was aware that a social worker was allocated to investigate this but they 
did not visit the ward while the patient was a resident.  

We then became aware that the patient’s daughter had raised safeguarding concerns 
against the Trust by email from Camden Social Services after the patient’s death. 
Her email alleged poor standards of care, inadequate nutrition and the development 
of oral thrush; as a result, this patient’s case was brought to the RFH Serious 

7 

 
 
   
 
 
 
 
 
 
 
 Incident Review Panel for discussion.   This presentation to the panel took place on 
27 March 2018.  The panel accepted that a Safeguarding conference of the care was 
required with a meeting planned to give evidence to the in-house Camden social 
work team and they asked that a “Learning from deaths” review be carried out. 

The safeguarding conference was held on the 15th of June in the Camden Social 
Work Office in South House, Royal Free Hospital. Further evidence from the patient’s 
notes was requested and following this, the case was closed by Camden against the 
hospital with no further action required. 

The “Learning from Deaths” review was carried out by one of our Royal Free Hospital 
Palliative Care Consultants, who was independent of the team that were treating this 
patient. This Consultant reviewed all of the patient’s notes and was unable to identify 
any issues of concern other than that he thought due to the obvious decline in the 
patient’s health, consideration of palliative care should have been made sooner.  He 
said that there was good documentation of care and observations, etc. He noted that 
there was evidence of pressure area and falls risk assessments.  He noted that there 
were thorough capacity assessments done, with the involvement of the multi-
disciplinary team.  Furthermore, he has noted that the patient was given “all 
treatment to improve her condition” but he felt that further interventions, such as the 
insertion of the NG tube, could have been avoided if her deterioration had been 
accepted as a sign that switching the emphasis of care to symptom control and 
comfort measures was appropriate. 

Following the inquest and the further concerns raised by the family of the care given 
to Dr Baber in the hospital, another Safeguarding conference was held with leads 
from Camden Social Services on the 18/09/2018, attended by the Adult Safeguarding 
Lead for the Trust and  the Camden CCG Safeguarding Lead. The outcome from this 
meeting was that due to the added concerns raised, which had not been shared 
previously, further investigation was necessary. As the hospital was completing this 
response to your Prevention of Deaths Report, with all the concerns raised within it, 
Camden will accept this response in lieu of a Section 42 Care Act (2014) report. It 
was also agreed that we would partake in an ‘After Action Review’ so that Camden 
Social Services could confirm that all actions promised within this report were being 
completed.  

Furthermore, as indicated above, the Clinical Practice Educator (CPE) on Ward 8 
West has introduced a HCA study day, specifically focusing on elderly care.  This is a 
rolling programme that currently includes input from safeguarding leads; mouth care; 
managing patients with dementia; how to raise concerns on Datix; and, the 
importance of thorough documentation.  There is also a weekly rolling teaching 
session for all staff on Ward 8 West which focuses on different aspects of care each 
month. 

We have set out below an Action Plan which summarises all of the actions that we are 
taking, as explained above, in response to your concerns. 

If you require any further information please do not hesitate to contact me. 

Thank you for bringing these matters to the Trust’s attention and providing us with an 
opportunity to further review and improve our processes.  The Trust is continuously seeking 
to improve the quality and safety of the care that it provides to its patients and your 
Preventing Future Deaths Report has been a helpful contribution to this ongoing and 
extremely important process. 

8 

 
 
 
 
 
 
 
 
 
 
 Yours sincerely, 

Dr Robin Woolfson 
Medical Director 
Royal Free Hospital 

9