Daniel Xavier

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

www.bartshealth.nhs.uk 

26 August 2022 

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

Dear Mr Irvine 

Re:  Regulation 28 Report to Prevent Future Deaths 

I write regarding your letter of 1 July 2022 regarding your concerns relating to the death of Daniel 
John Xavier at Newham University Hospital.  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. Venous Blood Gas (VBG) result not reviewed and therefore not acted upon prior to 
discharge 

In response to this incident, the Emergency Department (ED) are piloting a new process for the 
management of VBG results.  The process requires the person taking blood to take the result for 
sign off straight away and there is an allocated clinician who is dedicated solely to review VBGs, sign 
ECGs and take any resulting actions immediately. The effectiveness of this process and the 
additional resources required will be evaluated by October 2022 and developed using quality 
improvement methodology.    

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 In the medium term, the department is examining whether VBGs can be tracked on the electronic 
patient records system in the same way as happens with ECGs.  This would have the additional 
benefit of providing a more robust audit trail than paper and giving an immediate alert that a test had 
been completed.  

Learning from the incident has been shared widely within the department, including at induction and 
at daily safety briefings.  Furthermore, all staff have been briefed on the need for 3 pauses for safety, 
whereby checks are undertaken when the result is first available, then rechecked at the point of 
referral/movement to SDEC (Same Day Emergency Care) unit and then a further check at the point 
of discharge. 

2.  Chaotic referral from the patient’s GP to the surgical team 

The Trust is working with senior colleagues from primary care to improve the system.  Consideration 
is being given to introducing a single referral telephone line where calls are screened and accepted.  
We expect to have agreed a system by the end of October 2022.  The principle will be that there is 
automatic acceptance of referrals from GPs.   

The site is developing internal professional standards for speciality teams reviewing patients in the 
emergency department.  This will include training on where to find all relevant information including 
tests carried out and GP consultation within the electronic patient records system. The expectation is 
to have these agreed by the end of October 2022 

With regards to the internal processes within ED, it has been agreed that the clinician assessing the 
patient should document the immediate management plan (including tests and treatment) on the 
Cerner (electronic patient records system) record.  

3. Due regard not given to the patient’s learning disability 

Within ED, all patients with a learning disability will have the vulnerable patient flag applied to them 
on the electronic patient records system to raise awareness.  As part of an SOP, all patients with a 
learning disability will be discussed with by a senior clinician (ST3 plus) as a minimum and prioritised 
for early review.  The SOP is part of the induction package. 

Across the hospital, all specialities will be asked to have learning disability (LD) training during their 
governance days this year.  The hospital currently has a LD nurse on site 2 days a week and with 
future appointments will have one 4-5 days a week.  There will be a LD section as part of statutory 
and mandatory training by the end of the year.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Thank you for bringing your concerns to my attention. I trust that you are assured that I have 
taken them seriously and 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

From Maria Caulfield MP 
Parliamentary Under Secretary of State 
Department of Health & Social Care 

15 December 2022 

Mr Graeme Irvine 

East London Coroner’s Court 

127 Ripple Road 

Barking 

Essex 

Dear Mr Irvine,  

Thank  you  for  your  letter  of  1  July  2022  about  the  death  of  Daniel  John  Xavier.  I  am 
replying as Minister with responsibility for Mental Health and Women’s Health Strategy and 
disabilities at the Department of Health and Social Care.     

I would like to begin by offering my deepest condolences to the family and loved ones of 
Mr Xavier.  It is vital that we take learnings where they are identified to improve NHS care 
and I am grateful to you for bringing these matters to my attention. 

In preparing this response, Departmental officials have made enquiries with NHS England 
and the  Care Quality Commission  (CQC).  I  am  also  aware  that  Barts Health  NHS  Trust 
have responded to you directly to outline the steps they are taking to address the concerns 
that you raised in your report. 

The  Government  is  aware  that  people  with  a  learning  disability  and  autistic  people  can 
face  barriers  to  accessing  the  right  health  care  and  support  and  we  are  working  hard  to 
remove these. 

The ‘Learning from lives and deaths – People with a learning disability and autistic people 
programme’  (LeDeR)  provides  the  largest  body  of  evidence  of  deaths  of  people  with  a 
learning disability  at  an  individual level anywhere  in  the  world.   Everyone  with  a  learning 
disability aged 18 years and over is eligible for a LeDeR review to enable us to build up a 
detailed  picture  of  key  improvements  needed,  both  locally  and  at  a  national  level  to 
improve the care of hundreds of thousands of people with a learning disability and autistic 
people  and  to  reduce  the  health  disparities  faced  by  this  group  of  people.    I  understand 
that  Mr  Xavier’s  death  was  notified  to  the  LeDeR  programme  on  15  August  2022.    His 
LeDeR review has been allocated to a local LeDeR reviewer and the review is under way.  
Following confirmation that the death is within scope of the programme, a trained LeDeR 
reviewer will gather details on the death and look at key episodes of health and social care 
the  person  received  that  may  have  been  relevant  to  their  overall  health  outcomes.    For 

 
 
 
 
 
 
 
 
 
 
 
 some  reviews,  this  will  lead  to  a  more  comprehensive  “focused”  review,  looking  very 
closely  at  the  person's  life  and  circumstances  of  death.    These  focused  reviews,  once 
completed, are then sent to local governance groups with areas of good practice, areas of 
concern, and wider learning from the case being outlined. 

In addition to this, learning from LeDeR reviews has helped to inform what further action is 
required to reduce avoidable deaths.  One of the commonly reported learning points from 
LeDeR reviews is the need for greater learning disability and autism awareness training for 
staff in health and social care settings. 

Introducing  mandatory  training  is  an  important  way  in  which  we  can  address  persistent 
disparities  in  health  and  care  outcomes  for  people  with  a  learning  disability  and  autistic 
people  as  evidenced  from  LeDeR  reports.    That  is  why  the  Government  have  now 
introduced a requirement for CQC registered service providers to ensure their employees 
receive  learning  disability  and  autism  training  appropriate  to  their  role,  as  set  out  in  the 
Health and Care Act 2022, which came into force on 1 July 2022. 

To support this new training requirement, the government have made significant progress 
on the Oliver McGowan Mandatory Training which was trialled in England during 2021 with 
over 8000 people. Part one of the training – an e-learning package – is now available. 

This  training  is  intended  to  ensure  that  health  and  social  care  staff  have  the  skills  and 
knowledge  to  provide  safe,  compassionate  and  informed  care  to  people  with  a  learning 
disability and autistic people.  All staff will receive training on how a learning disability and 
autism can affect people, what reasonable adjustments are and how to make them.  Staff 
that are more likely to engage with people with a learning disability and autistic people will 
receive further training on reasonable adjustments and communication, including hospital 
passports,  professional  behaviour,  and  how  to  communicate  in  an  accessible  way  and 
understand what the person and their family are saying. 

Furthermore, the Secretary of State will publish a Code of Practice that will outline how to 
meet  the  new  requirement  for  mandatory  training  including  its  content,  delivery,  ongoing 
monitoring  and  evaluation.    The  government  will  carry  out  a  public  consultation  on  the 
Code of Practice and timings for this consultation are currently being considered. 

I hope this response is helpful. Thank you for bringing these concerns to my attention. 

Kind regards, 

 MARIA CAULFIELD