Moses Boardman

Bera

I amet: Barts Health

12 OCT 2020 | NHS Trust

POPLAR CO RO! YER Trust Executive Office
COURT Ground Floor
— : Pathology and Pharmacy Building
The Royal London Hospital
80 Newark Street
London Ei 2ES

Telephone:

Date: 9" October 2020

Private & Confidential
Mr Graeme Irvine
HM Assistant Coroner for Inner London

North
° Deputy Chief Medical Officer

www.bartshealth.nhs.uk

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 11" 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.

41. The absence of a 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 being completed.

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, action was taken for this concern at the time of the SI Investigation. The
departure lounge clarified in their SOP that when a 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 suitability of the venue

that a patient is being taken to.

The trusts transport team have a safeguarding process for completion when a discharge
destination raises concerns. At the time of the incident the process that the crews follow
was similar to the rest of the Trust, they will raise both safeguarding and 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 return the patient to hospital. Direction is then taken
from the ward, if they 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 and this process will be amended according to their
findings. ,

4. 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 patients on RLH ward 14f who have been assessed as

being “fed at risk”. Specifically, why was a vulnerable patient left with unsuitable
foods within his reach.
The trusts clinical guidelines “Guidelines for Best Practice: Eating 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.

NHS

Barts Health
NHS Trust

6. The RLH failure to commence CPR when a potential reversible cause for collapse
existed that would override 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 bite of the kiwi fruit. This related to poor blood flow to the
brain, fitting with the description 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.

Yours sincerely

Dr .
Deputy Chief Medical Officer

Response to Regulation 28 report arising out of the inquest regarding Mr Boardman 

(died 27.12.2019) on behalf of the London Borough of Tower Hamlets 

The matters of concern raised which LBTH are to respond to is (4):- 

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 three care visits 

Three Sisters Care not informing the LA that they had been unable to provide care to 
MB as arranged.   
The Failed Visits policy requires all commissioned domiciliary care providers to 
inform the local authority speedily of all occasions when the provider is unable to 
provide care as arranged because the provider does not seem to be at home or does 
not admit them.  Commissioned providers are routinely reminded of the Failed Visits 
policy at quarterly providers meetings and the importance of adhering to the policy 
will be reiterated to them at the next forum. The quality of service provided by Three 
Sisters Care is currently under review with the lead commissioner requiring targets 
on an improvement plan to be met. Failure to achieve the standards required may 
result in the provider being de-commissioned.  

Sue Starkey House not informing the LA that MB did not arrive with them from 
hospital as expected.  
The lead commissioner will speak to the provider and remind them of the 
importance of letting the emergency duty team know if a patient does not arrive as 
expected from hospital discharge. 

London Borough of Tower Hamlets 

12th October 2020