Thomas Doyle

Executive Offices, Trust Headquarters 
Queen's Hospital 
Rom Valley Way, Romford, RM7 0AG 

Private & Confidential 

Mr G Irvine 
HM Senior Coroner Walthamstow Coroner’s Court 
Queens Road 
London 
E17 8QP 

14 December 2023 

Dear Mr Irvine, 

Regulation 28 Report on the death of Mr. Thomas Doyle 

Thank you for your Regulation 28 Report dated 20 October 2023. The Trust has carefully considered the concerns 
raised in the learned Coroner’s report, and guidance has been sought from specialists within the Trust to address 
them. 

The matters of concern identified in the Regulation 28 report and the Trust`s responses are set out below: 

1.  The Trust’s clinical records were of particularly poor standard which impeded the Trust’s governance 
investigation and the inquest investigation in determining what, if any consideration was given to the 
possibility of Mr. Doyle was suffering from an infection. 

Trust`s response  

The Trust has completed a number of actions and has actions ongoing: 

• 

• 

• 

• 

• 

An Internal Alert has been shared with staff via email, Alert reference 
9 November 2023 which details good record keeping standards that should be adhered to by all staff. 
A video has been developed and was placed on the Trust intranet 27 November 2023 which shows 

 Issued Date  

 - Medical Director (Patient Safety and Patient Experience), explaining the importance of good 

record keeping. 
A screen saver was agreed and appeared on all Trust computer screens week commencing  
4 December 2023 
PFD concerns and record keeping standards have been discussed at clinical group quality and safety 
meetings during October and November 2023. 
The Medical Director has discussed PFD concerns with the Clinical Group Directors and requested they 
ensure attendance of named clinicians to attend the Trust Sepsis Group. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 • 

• 

• 

• 

All medical staff must complete a record keeping module on the Trust BEST learning management system 
that allows staff to undertake e learning module on their first day working at the Trust. Record keeping 
for nursing staff is included in the nursing preceptorship programme. 
There is a mandatory field on the new electronic record asking the question 'is sepsis suspected' if yes this 
triggers the sepsis pathway and data is captured that way. Monthly audit of this takes place with the 
latest results showing 100% compliance of the records audited. 
The Trust sepsis education programme is essential for all clinical staff and has recently been 
updated.  This is supported by additional face to face training for doctors and nurses. 
The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited by the Lead 
Nurse for Sepsis.  Audits include patients who have scored over 5 on the National Early Warning Score to 
ensure that Sepsis was considered.  In addition, all positive blood culture cases are audited to ensure 
compliance with the Sepsis 6. 

•  Most recent audits show that compliance with commencing the Sepsis 6 sat at 97% percent for adult 

• 

• 

• 

• 

• 

inpatient areas with 100% compliance in ED and Acute Medicine. 
Sepsis mortality reviews are scheduled on a rolling basis. The raw data is sent externally to a central 
review body in Birmingham. The data is analyzed with internationally accepted health modelling data to 
see if mortality rates are in keeping with that expected for the case mix in the hospital catchment area. 
These do not indicate failings in care but help each Trust to examine their processes.  
Structured review of individual sepsis mortalities is completed internally in the Trust using defined 
criteria. A presentation of both external and internal reviews is made to the Sepsis Steering Committee 
every two months. 
ED services have registered a medical records audit which will commence December 2023 and complete 
31 January 2024, on the new electronic Careflow record, ensuring the free text sections are being 
completed to the Trust and professional standards. The audit report will be shared with all teams and 
action plan agreed for any identified areas of concern; the audit will be overseen by the Trust Audit 
Committee. 
Acute Medicine have regular weekly teaching sessions within which sepsis is the most regular topic on 
both sites.  
The Antimicrobial Point Prevention Audit for October 2023 shows MAU KGH achieved 100% which 
reflects the teaching and learning of the staff. This is a monthly audit. 

•  Monthly assurance walkabouts in clinical areas; the audit is completed monthly on both sites by the band 
7 nurses, they audit 10 sets of notes each month selected from patients who present with primary mental 
health presentation. The audit comprises of a variety of questions that monitor aspects of care including if 
safeguarding referrals have been made, risk assessments completed, nursing care risk assessments have 
been completed, incident report for rapid tranquilisation and compliance with enhanced 
observations. Matrons oversee the audits, results, and actions. Audit results are shared monthly at the 
speciality meeting and learning is shared between the two Emergency Departments. This is minuted in 
the meetings. Learning for the individual departments is shared with the staff through their daily safety 
brief which takes place at the twice daily huddle. Audit synopsis is shared with the team at the safety brief 
and printed and available in the staff room. The information is available for temporary workers who will 
attend the team brief and will also have access to the printout.   

 
 
 
 
 • 

The BHRUT Ward Accreditation framework is bespoke although informed by learning from other trusts. It 
involves reviewing processes, procedures and systems which support excellence. Every ward has a 
different journey, based on the findings of initial assessments. Issues that form collective challenges can 
be identified and inform Trust-wide improvement efforts. Benefits of the programme include:  

o 

reducing unwanted variation by providing an evidence-based, standardised approach to supporting 
the delivery of care and improving quality  

o  helping staff understand what is expected at ward level by providing a clear set of standards and a 

o 
o 
o 

measure of how well they are doing in delivering quality care 
improving patient outcomes and experience 
recognition and appreciation for those teams that receive an accreditation award 
Increased teamwork across BHRUT. Shared assessments are undertaken by the Ward Accreditation 
Core Team alongside Subject Matter Experts (SMEs) and Patient Partners. Wards are selected 
randomly unless there is a particular concern which may trigger assessment. The assessment is 
carried out over five days. Information is collated and certificates denoting level of accreditation 
are presented by the Chief Nurse to the Ward Manager and Ward Team within two weeks of 
assessment. To date 38 clinical areas have been assessed with the plan to have assessed all clinical 
areas by April 2024. 

2.  The Trust’s failure to commence a diagnostic pathway to investigate sepsis when clearly indicated on 

Mr. Doyle’s admission, as required by both local policy and national guidance. 

Trust`s Response 

The Trust advises that there had been a number of significant improvements since the incident occurred: 

• 
• 

Sepsis screening in the Emergency Departments has significantly improved (evidenced by audit data) 
The Emergency Departments now use an electronic record, Careflow, which amongst several mandatory 
fields has a mandatory question with respect to consideration of sepsis. 

•  Monthly sepsis group oversight of sepsis management 
• 

Record keeping standards included in nursing preceptorship programme and junior doctors’ induction. 

The Trust has taken the issues identified by the Learned Coroner very seriously and has taken positive action to 
address those issues. 

I would be happy to meet to discuss this response if that would be helpful to HM Coroner. 

Yours sincerely, 

Chief Executive

From Minister Caulfield 
Minister of State for Patient Safety 

39 Victoria Street 
London 
SW1H 0EU 

8 May 2024 

Mr G Irvine 
Walthamstow Coroner’s Court 
124 Queens Road 
London 
E17 8QP 

Dear Mr Irvine, 

Thank you for your Regulation 28 report to prevent future deaths of 20 October 2023 about 
the death of Thomas Doyle. I am replying as Minister with responsibility for Patient Safety. 

Firstly, I would like to say how saddened I was to read of the circumstances of Thomas Doyle, 
and I offer my sincere condolences to their family and loved ones. The circumstances your 
report  describes  are  concerning  and  I  am  grateful  to  you  for  bringing  these  matters  to  my 
attention. Please accept my sincere apologies for the delay in responding to this matter. 

The report raises concerns over the poor standards of the Trust’s clinical records which 
impeded the Trust’s governance investigation and the inquest investigation in determining if 
any consideration was given to the fact that Mr Doyle was suffering from an infection and the 
Trust also failed to commence a diagnostic pathway to investigate sepsis when clearly 
indicated on Mr Doyle’s admission, as required by both local policy and national guidance.    

In preparing this response, Departmental officials have made enquiries with NHS England and 
the Care Quality Commission (CQC). The Trust has taken the issues identified very seriously 
and has taken positive action to address those issues. To improve standards, an internal alert 
and a screen saver has been shared with staff which details good record keeping standards 
that should be adhered to by all staff as well as a video which has been developed with the 
Medical Director explaining the importance of good record keeping.  

PFD  concerns  and  record keeping  standards  have been  discussed  at  clinical  group  quality 
and safety meetings and the Medical Director has discussed PFD concerns with the Clinical 
Group Directors and requested they ensure attendance of named clinicians at the Trust Sepsis 
Group. All medical staff must complete a record keeping module on the Trust BEST learning 
management system that allows staff to undertake e learning module on their first day working 
at  the  Trust.  Record  keeping  for  nursing  staff  is  included  in  the  nursing  preceptorship 
programme.  

There  is  a  mandatory  field  on  the  new  electronic  record  asking  the  question  'is  sepsis 
suspected' if yes this triggers the sepsis pathway and data is captured that way. Monthly audit 
of this takes place with the latest results showing 100% compliance of the records audited.   

1 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 The Trust sepsis education programme is essential for all clinical staff and has recently been 
updated. This is supported by additional face to face training for doctors and nurses.  

The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited 
by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National 
Early  Warning  Score  to  ensure  that  Sepsis  was  considered.  In  addition,  all  positive  blood 
culture cases are audited to ensure compliance with the Sepsis 6. Most recent audits show 
that compliance with commencing the Sepsis 6 sat at 97% percent for adult inpatient areas 
with 100% compliance in ED and Acute Medicine.  

Sepsis mortality reviews are scheduled on a rolling basis. The raw data is sent externally to a 
central review body in Birmingham. The data is analyzed with internationally accepted health 
modelling data to see if mortality rates are in keeping with that expected for the case mix in 
the  hospital  catchment  area.  These  do  not  indicate  failings  in  care  but  help  each  Trust  to 
examine their processes.   

Structured  review  of  individual  sepsis  mortalities  is  completed  internally  in  the  Trust  using 
defined criteria. A presentation of both external and internal reviews is made to the Sepsis 
Steering  Committee  every  two  months.    Acute  Medicine  have  regular  weekly  teaching 
sessions within which sepsis is the most regular topic on both sites.  There are also monthly 
assurance  walkabouts  in clinical  areas; the  audit  is  completed  on  both  sites by the band  7 
nurses,  who  audits  10  sets  of  notes  each  month  selected  from  patients  who  present  with 
primary mental health presentation. The audit comprises of a variety of questions that monitor 
aspects  of  care  including  if  safeguarding  referrals  have  been  made,  risk  assessments 
completed,  nursing  care  risk  assessments  have  been  completed,  incident  report  for  rapid 
tranquilisation  and  compliance  with  enhanced  observations.  Matrons  oversee  the  audits, 
results, and actions. Audit results are shared monthly at the speciality meeting and learning is 
shared between the two Emergency Departments. This is minuted in the meetings. Learning 
for  the  individual  departments  is  shared  with  the  staff  through  their  daily  safety  brief  which 
takes place at the twice daily huddle. Audit synopsis is shared with the team at the safety brief 
and printed and available in the staff room. The information is available for temporary workers 
who will attend the team brief and will also have access to the printout. 

Specifically  on  the  Trust’s  failure  to  commence  a  diagnostic  pathway  to  investigate  sepsis 
when  clearly  indicated  on  Mr.  Doyle’s  admission,  the  Trust  advises  that  there  had  been  a 
number  of  significant  improvements  since  the  incident  occurred.    Sepsis  screening  in  the 
Emergency  Departments  has  significantly  improved  (evidenced  by  audit  data).  The 
Emergency  Departments  now  use  an  electronic  record,  Careflow,  which  amongst  several 
mandatory fields has a mandatory question with respect to consideration of sepsis. Monthly 
sepsis group oversight of sepsis management  Record keeping standards included in nursing 
preceptorship programme and junior doctors’ induction. 

I am also informed, that the CQC published their report following an inspection carried out into 
the  Trust,  which  operates  from  two  sites:  Queen's  Hospital  and  King  George  Hospital,  in 
December.  CQC  established  that  the  emergency  departments  had  improved  at  the  Trust, 
however, the service at the Trust ‘requires improvement overall’. The report identifies several 
actions  the  service  must  take  that  are  necessary  to  comply  with  its  legal  obligations.  It  is 
encouraging  to  note  that  CQC  will  continue  to  monitor  the  trust’s  progress  regarding  the 
matters raised in the report and wider concerns identified by way of their inspection.  

Finally, in February the Government and NHS England announced plans to implement 
Martha’s Rule in at least 100 acute or specialist NHS sites in England by March 2025. 
Martha’s Rule is an initiative that gives patients and their families who are concerned about 
deterioration in their physiological condition the right to initiate a rapid review of their case 24 

 
 
 
 
 
 
 hours a day from someone outside of their immediate care team. When requested, this rapid 
review will inform whether any new or additional action needs to be taken to help ensure 
patients receive the most appropriate care and treatment – which may include escalation.   

I  hope  this  response  is  helpful  and  assures  you  that  the  issues  raised  have  been  taken 
seriously and steps undertaken to address these. Thank you for bringing these concerns to 
my attention.  

Yours sincerely, 

MARIA CAULFIELD