Amarbai Bhudia

Our Ref: 
Your Ref: 

19 January 2021 

Mr Graeme Irvine 
Area Coroner – East London 
Walthamstow Coroner’s Court 
Queen’s Road 
London 
E17 8QP 

Dear Mr Irvine 

Trust Executive Office 
Ground Floor 
Pathology and Pharmacy Building 
The Royal London Hospital 
80 Newark Street 
London E1 2ES 

Telephone: 

Chief Medical Officer 

      www.bartshealth.nhs.uk 

Re:  Regulation 28 Report to Prevent Future Deaths 

I  write regarding  your  letter  of  12  November  2020  regarding  your  concerns relating to the  death of 
Amarbai Bhudia at Newham University Hospital.  I apologise for the length of time it has taken to get 
this  response to  you,  which  was  due  to  the  necessity  to  respond  to  immediate  challenges  brought 
about by the pandemic surge.  I hope this letter will provide assurance to you of the steps that we are 
taking to address the concerns you have outlined.  I will respond to these concerns in turn. 

1.  Instructions  on  the  management  of  the  NG  tube  were  provided  on  a  ward  round  by  a 
consultant,  the  instructions  were  not  clearly  noted  by  the  House  Officer  accompanying  the 
consultant. 

In  response  to  concerns  in  the  department  of  surgery  regarding  the  quality  and  content  of 
communications  about  clinical  instructions,  an  audit  was  designed  and  implemented  by  the  junior 
surgery  team.  This  identified  that  there  was  a  need  for  a  structured  ward  round  template,  and 
showed that implementation of a structured ward round improved communication on the ward.  This 
audit  was  accepted  for  presentation  at  The  Royal  College  of  Surgeons  of  Edinburgh,  though  the 
conference did not take place due to the pandemic.   

2.  Nursing staff had no clinical instruction as to how to manage the NG tube 

A teaching session regarding Nasogastric Tube Placement was devised by the Barts Health Clinical 
Skills Facilitators and delivered to the teams on the wards by the Ward Managers and Professional 
Development nurse, and the slides used were shared by email with all staff.  The teaching material 
included:  

Information about responsibilities of staff. 
Indications for nasogastric tube insertion. 

 
 
  Contraindications for nasogastric tube insertion. 
 

Information about high risk patients. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Complications associated with nasogastric tube insertion. 
  An overview of National Patient Safety Agency (NPSA) guidance. 
  Equipment required. 
  NEX (nose to ear to xiphisternum) measurement. 
  Head positioning during placement. 
  Tube fixation. 
 
  Confirming tube placement. 
  Post procedure action. 
  Subsequent testing. 
  Use of a Ryles tube for drainage. 
  Removal of nasogastric drainage tubes. 

Insertion procedure. 

Furthermore,  a  new  assurance  template  has  been  introduced  to  spot-check  the  presence  of  the 
nursing team on ward rounds. The medical plans are entered into a diary by the nurses to ensure the 
plans  are  communicated  effectively.  The  Nurse  in  Charge  checklist  has  now  been  introduced 
including clear guidance regarding the roles and responsibilities of the person coordinating the ward 
area.   

We  have  introduced  a  Consultant  Surgeon  of  the  week  model,  with  the  same  Consultant  from 
Monday to Friday, and one for the weekend. This provides consistency and continuity of cover and 
helps to ensure good communication with all members of the multidisciplinary team; as the nursing 
team,  nurse  in  charge  and  AHPs  have  a  single  point  of  contact  for  questions  and  escalation.  This 
makes for better team working and safety culture. 

The  Trust’s  nasogastric  and  orogastric  policy  has  been  revised,  including  the  use  of  free  drainage 
and regular aspiration (suctioning).  The Trust Corporate Policy: Nasogastric/ orogastric tube policy 
(adults)  was  updated  and  approved  on  24  July  2020  and  includes  information  about  the  use  of 
nasogastric tubes for drainage of stomach contents.   

3.  Nursing  staff  dealing with the  patient  were  agency  staff without  training  or  experience  of 
NG tube management 

The Trust’s Induction Policy has been reviewed and revised (August 2020) to ensure that it includes 
assurances  that  temporary  staff  are  competent  to  carry  out  the  care  and  treatment  of  the  patients 
they are allocated on the particular shift. 

This  policy  included  the  Barts  Health  Local  Induction  Checklist  for  permanent  staff  and  the  Local 
Induction  Checklist  for  temporary  non-medical  clinical  staff  (for  use  on  all  Barts  Health  sites).    The 
booking system now records the specialist skills of temporary workers, both Bank and Agency, and 
prevents  the  booking  of  a  temporary  worker  who  does  not  possess  skills  identified  on  the  booking 
request. 

In  order  to  ensure  that  all  temporary  workers  have  a  robust  induction  to  the  clinical  area,  a 
comprehensive local induction pack has been developed and is provided by the Ward Manager to all 
new temporary workers.   

 
 
 
 
 
 
 
 
 
 
 Use  of  the  induction  pack  ensures  that  the  Nurse  in  Charge  reviews  the  competency  of  the 
temporary  worker  to  provide  safe  and  effective  care  to  the  patient  or  patients  they  have  been 
allocated  prior  to  starting  work,  and  allows  learning  to  take  place  or  for  changes  in  the  staffing 
allocation to be made to safeguard patients.  When possible the clinical areas strive to use staff that 
have been assessed as competent in preference to a worker that is unfamiliar with the clinical area 
or the conditions encountered in the clinical area. 

Since the incident the Ward Manager on East Ham Ward, has led on improving the knowledge and 
skills  of the  nursing  workforce,  and  ensuring  that  the temporary  workers  allocated  in Surgery  meet 
the requirements of the service and are safe to practice.   

4. Concerns regarding the NG tube function were not properly escalated to clinical staff 

A local induction guide has been produced which clearly outlines  what is expected of staff working 
on East Ham ward. Within it are multiple examples of the process of escalation, including the nursing 
staff being empowered to escalate to Consultants if not getting a response from junior doctors. 

Thank you for bringing your concerns to my attention. I trust that you are assured that I have taken 
them  seriously,  that  the  hospital  has  investigated  them  appropriately  and  is  taking  appropriate 
action.  Please let me know if you require clarity on any of the points above.  

Yours sincerely 

Chief Medical Officer 

Barts Health NHS Trust 

Encl: 
Surgical ward round documentation: a quality improvement project  
Correspondence from The Royal College of Surgeons of Edinburgh