Roy Travers

Private and Confidential 
HM Coroner Mary Hassell 
Senior Coroner 
Inner North London 
St. Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

28 December 2022 

Dear Senior Coroner Hassell 

Medical Director and Responsible 
Officer 
Medical Directorate 
Jenner Building 
Magdala Avenue 
London N19 5NF 

t  
www.whittington.nhs.uk   

Re: Regulation 28 Prevention of Future Deaths ( PFD) 

I am writing to respond to the Regulation 28 Prevention of Future Deaths 9PFD) report 
for Roy Travers. This response is written on behalf of Whittington Health. Following 
the  inquest,  you  raised  the  following  matters  for  concern  and  the  actions  we  have 
taken in response to these concerns are as follows: 

Matter  of  concern  1-  Melaena  was  noted  at  8.45am  on  4  June  2022,  but  it  was 
another 12 hours before medical staff reviewed Mr Travers. There appears to have 
been a failure to escalate. A doctor was asked to see him earlier that day, but about a 
different issue.  

The Ward manager 
 has given feedback to the nurse who did not 
escalate melaena. The nurse has booked to attend a course in January 2023 which 
includes how to recognise and manage the deteriorating patient. This course will re-
enforce  knowledge,  improve  competence,  encourage  better  communication,  and 
enhance team working. This course is run by the Critical Care Outreach Team.  

Further  training  for  ward  nurses  is  being  put  in  place  to  cover  the  recognition  and 
escalation of gastrointestinal bleeding is being organised by the Associate Director of 
Nursing and will be led by the endoscopy nursing team.   

Matter of concern 2 - As identified at the Whittington 72-hour review, the reviewing 
doctor  who  later  considered  Mr  Travers’  condition  in  the  light  of  the  melaena,  then 
failed to withhold his anti-coagulation therapy, apixaban. It is unclear from the review 
whether that doctor has since been given direct feedback and a learning opportunity.  

Direct feedback and learning were given to the reviewing doctor by their Educational 
Supervisor, as confirmed in an email on 9 June 2022. 

The following aspects were covered: 

Whittington Health NHS Trust 

Helping local people live longer healthier lives 

 
 
 
          
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 1. 

Assessment of gastrointestinal bleeding using a systematic approach A-E to 
assess an unwell patient  
Stopping anticoagulation/reversal 

 2. 
 3.   Repeat blood tests and handover of these patients.  
 4.   Documentation of the Glasgow Coma Scale.  

Matter of concern 3 - The 72-hour review identified the need to discuss Mr Travers’ 
care  at  the  relevant  morbidity  and  mortality  meeting.  It  is  unclear  from  the  review 
whether that discussion has taken place.  

The discussion of this case took place on 21 July 2022 at an Acute Medicine team 
mortality and morbidity meeting. This meeting was chaired by Dr. 
, the 
mortality  lead  for  Acute  Medicine.  The  case  was  presented  and  led  by  Dr 

,  Associate  Medical  Director 

Improvement  and  Clinical 
Effectiveness.  The  meeting  was  attended  by  other  Consultants  in  Acute  medicine, 
junior doctors, and nurses. The above is confirmed in an email on 2 December 2022 
sent  to  the  Associate Medical  Director for Patient  Safety  and Learning  from  Death. 

for  Quality 

Matter of concern 4 - Mr Travers’ sons told me at inquest that, when Mr Travers’ was 
nursed on Mary Seacole Ward, they felt that staff regarded this confused, elderly man 
as  a  nuisance.  That  is clearly  unacceptable.  In  addition,  Mr Travers’  family  worried 
that this view of him clouded the judgement of those looking after him.  

 Ward Manager of Mary Seacole, offers her sincere condolences to 
Mr  Travers’ family. Ms Bakari advises Mr Travers had an electronic alert to notify staff 
of his additional care needs due to his dementia. Due to his risk of dehydration 

  herself  supported  to  insert  a  new  intravenous  cannula.  A  1:1  was  also 
implemented to support his safety (prevention of falls risks) whilst he was being nursed 
in a side room. There is clear documentation that nursing staff were supporting him 
with  taking oral fluids and  offering  food  and assisted  him  with  his personal hygiene 
needs. Staff regularly care for patients with confusion but 
  felt Mr Travers 
needs while confused were manageable on the ward and appropriate to the skills of 
the staff.  

 offers apologies to the family for the perception of the care. 

Matter of concern 5 - As you will be aware, an ancillary function of every inquest is 
to  attempt  to  learn  lessons  from  the  death,  the  driver  behind  prevention  of  future 
deaths  reports.  However,  it  is  incumbent  upon  every  hospital  trust  to  consider  the 
deaths of those within its care long before the matter comes to inquest, and to attempt 
to learn from these if possible.  

Whittington Health NHS Trust 

Helping local people live longer healthier lives 

 
 
 
          
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 Whittington Health conducted a 72-hour review of Mr Travers’ 
care on 17 June 2022. This was disclosed to my coroner’s officer late on the afternoon 
of  Friday,  4  November,  in  preparation  for  an  inquest  listed  for 10am  on  Monday,  7 
November. 

This meant that Mr Travers’ family and I received the 72-hour review on the morning 
of inquest.  This had several consequences. 

 • 

•  

•  

•  

but 

also 

It placed family members in an unfair position in terms of their preparation for 
inquest.    
It did not comply with the duty to co-operate with HM Coroner, not simply when 
asked 
It denied HMC the ability to call to inquest any witnesses the need for whom 
only became apparent from the review. 
And  it  did  not  inspire  confidence  that  Whittington  Health  took  its  own  review 
seriously and tried to learn from it.  Even the Whittington consultant giving oral 
evidence at inquest only saw the review on the morning of inquest, and then 
purely as a result of being provided it by my coroner’s officer.   

volunteering 

relevant 

by 

all 

information.    

Mortality review meetings are led by the department mortality leads. There is evidence 
to support that these meetings are taking place, including provision of timely mortality 
reviews. These meetings provide opportunities to capture and share the learning from 
death. This case was discussed at a Mortality Meeting on 21 July 2022.The Associate 
Medical Director for Patient Safety and Learning from deaths collates the learning and 
reports this to the Trust board level Quality Assurance Meeting on a quarterly basis. 
This has continued throughout the COVID-19 pandemic.  

Learning from deaths have been shared in Grand rounds, highlighted in the Trust wide 
Patient Safety newsletter and the monthly Patient Safety Forum.  

The coroner has commented that her team had to share the 72-hour report with the 
consultant  giving  evidence.    The  legal  department  sent  the  72-hour  report  to  Dr 
 on 4 December 2022 by email – in the week prior to the inquest - but we fully 

accept that this should have been a much more timely process. 

In  preparing  this  response  the  Associate  Medical  Director  for  Patient  Safety  and 
Learning from Death has shared the information with Head of Nursing, Clinical teams, 
Patient Safety Group and the Quality Governance Committee. 

Yours sincerely  

Medical Director and Responsible Officer 

MBBS BSc PhD FRCP FFFMLM RCPathME (GMC 3360145) 

Whittington Health NHS Trust 

Helping local people live longer healthier lives