Prevention of Future Deaths reports · 2023

Jennifer Whinney

Regulation 28 report to prevent future deaths, reference 2023-0477, written 27 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report27 Nov 2023
Reference2023-0477
DeceasedJennifer Whinney
CoronerMelanie Lee
Coroner areaInner North London
CategoryChild Death (from 2015) · Hospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation 28:  Prevention of Future Deaths report 

Jennifer Ruth Whinney (died 2 November 2022) 

THIS REPORT IS BEING SENT TO: 

1.  Queens Hospital  

1 

CORONER 

I am:   Melanie Sarah Lee 
           Assistant Coroner  
           Inner North London 
           St Pancras Coroner’s Court 
           Camley Street 
           London N1C 4PP 

2 

CORONER’S LEGAL POWERS 

I make this report under the Coroners and Justice Act 2009,  
paragraph 7, Schedule 5, and The Coroners (Investigations) 
Regulations 2013, regulations 28 and 29. 

3 

INVESTIGATION and INQUEST 

On 17 November 2022 an investigation was commenced into the death 
of Jennifer Ruth Whinney aged 68. The investigation concluded at the 
end of the inquest on 17 November 2023. I made a determination at 
inquest that Jennifer died of multi-organ failure following septicaemia 
from infective PICC lines and following successful surgery to repair a 
bowel fistula. The medical cause of death was 1a. multi-organ failure, 
1b. septicaemia, 1c. recurrent line sepsis, enterocutaneous fistula 
repair, 2. ischaemic heart disease, hypertensive heart disease. 

4 

CIRCUMSTANCES OF THE DEATH 

In 2017 Jennifer underwent an emergency resection of her left colon and 
a  stoma  formation  at  Queens  Hospital  due  to  an  ischaemic  bowel.  A 
small area of the wound failed to heal and she was reviewed at Queens 
Hospital on several occasions in 2021 and 2022. She then presented to 
Queens Hospital as an emergency on 19 April 2022 when a large wound 
had  opened  up and  was  discharging  fluid and bowel  contents.  A scan 
revealed a fistula. She was managed conservatively to see if the fistula 
would heal by itself and this included inserting a PICC line to administer 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 nutrition so that the bowel could be rested. She had no problems with 
her PICC line whilst at Queens Hospital.  

She  referred  to  the  Colorectal  Specialist  Team  at  the  Royal  London 
Hospital  and  seen  in  late  May.  At  her  initial  appointment,  her  medical 
records were not sent with her and the surgeon reviewing her only had a 
referral letter.  

Jennifer was admitted to the Royal London Hospital on 12 July 2022 in 
preparation for surgery. She developed numerous infections to her PICC 
lines which led to sepsis.  

Jennifer underwent surgery to repair her bowel on 7 October 2022. The 
operation was uneventful and she recovered well. She then developed a 
further infection to her PICC line and died from multi-organ failure caused 
by septicaemia.  

5 

CORONER’S CONCERNS 

During the course of the inquest, the evidence revealed matters giving 
rise to concern. In my opinion, there is a risk that future deaths will occur 
unless  action  is  taken.  In  the  circumstances,  it  is  my  statutory  duty  to 
report to you. 

The MATTERS OF CONCERN are as follows.  

Jennifer  was  referred  to  the  colorectal  specialist  team  at  the  Royal 
London  Hospital and  seen  in  late  May.  The  witnesses  were  unable  to 
give me the exact date of the appointment. Jennifer’s notes were not sent 
to  the  appointment  with  her.  I  heard  that  patient  records  at  Queens 
Hospital are not electronic. Ward staff compile the notes which are sent 
physically  with  the  patient  if  they  attend  any  external  appointment.  I 
heard that no one person has responsibility for ensuring that the notes 
are sent. 

Jennifer was articulate and understood her health problems well and so 
was able to provide the colorectal surgeon with her medical background. 
I am concerned that another patient may not be able to provide such a 
full and accurate history and that critical information may not be passed 
on.  

6 

ACTION SHOULD BE TAKEN 

In  my  opinion,  action  should  be  taken  to  prevent  future  deaths  and  I 
believe that your organisation has the power to take such action.  

7 

YOUR RESPONSE 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 You are under a duty to respond to this report within 56 days of the date 
of this report, namely by 22 January 2024.  I, the coroner, may extend 
the period. 

Your  response  must  contain  details  of  action  taken  or proposed  to  be 
taken, setting out the timetable for action. Otherwise you must explain 
why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the following interested persons: 

• 
•  Royal London Hospital 

 (Jennifer’s daughter) 

And to: 

•  CQC 
•  HHJ Thomas Teague QC, the Chief Coroner of England & Wales  

I  am  also  under  a  duty  to  send  a  copy  of  your  response  to  the  Chief 
Coroner and all interested persons who in my opinion should receive it.  
I  may  also  send  a  copy  of  your  response  to  any  other  person  who  I 
believe may find it useful or of interest.  

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he  believes  may  find  it  useful  or  of  interest.  You  may  make 
representations to me, the coroner, at the time of your response, about 
the release or the publication of your response. 

9 

DATE                                           SIGNED BY ASSISTANT CORONER 
27 November 2023 

3
Also filed under 2023-0477: Jennifer-Whinney-Prevention-of-future-deaths-report-2023-0477_Published.pdf
Regulation 28:  Prevention of Future Deaths report 

Jennifer Ruth Whinney (died 2 November 2022) 

THIS REPORT IS BEING SENT TO: 

1.  The Royal London Hospital  

1 

CORONER 

I am:   Melanie Sarah Lee 
           Assistant Coroner  
           Inner North London 
           St Pancras Coroner’s Court 
           Camley Street 
           London N1C 4PP 

2 

CORONER’S LEGAL POWERS 

I make this report under the Coroners and Justice Act 2009,  
paragraph 7, Schedule 5, and The Coroners (Investigations) 
Regulations 2013, regulations 28 and 29. 

3 

INVESTIGATION and INQUEST 

On 17 November 2022 an investigation was commenced into the death 
of Jennifer Ruth Whinney aged 68. The investigation concluded at the 
end of the inquest on 17 November 2023. I made a determination at 
inquest that Jennifer died of multi-organ failure following septicaemia 
from infective PICC lines and following successful surgery to repair a 
bowel fistula. The medical cause of death was 1a. multi-organ failure, 
1b. septicaemia, 1c. recurrent line sepsis, enterocutaneous fistula 
repair, 2. ischaemic heart disease, hypertensive heart disease. 

4 

CIRCUMSTANCES OF THE DEATH 

In 2017 Jennifer underwent an emergency resection of her left colon and 
a  stoma  formation  at  Queens  Hospital  due  to  an  ischaemic  bowel.  A 
small area of the wound failed to heal and she was reviewed at Queens 
Hospital on several occasions in 2021 and 2022. She then presented to 
Queens Hospital as an emergency on 19 April 2022 when a large wound 
had  opened  up and  was  discharging  fluid and bowel  contents.  A scan 
revealed a fistula. She was managed conservatively to see if the fistula 
would heal by itself and this included inserting a PICC line to administer 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 nutrition so that the bowel could be rested. She had no problems with 
her PICC line whilst at Queens Hospital.  

She  referred  to  the  Colorectal  Specialist  Team  at  the  Royal  London 
Hospital  and  seen  in  late  May.  At  her  initial  appointment,  her  medical 
records were not sent with her and the surgeon reviewing her only had a 
referral letter.  

Jennifer was admitted to the Royal London Hospital on 12 July 2022 in 
preparation for surgery. She developed numerous infections to her PICC 
lines which led to sepsis.  

Jennifer underwent surgery to repair her bowel on 7 October 2022. The 
operation was uneventful and she recovered well. She then developed a 
further infection to her PICC line and died from multi-organ failure caused 
by septicaemia.  

5 

CORONER’S CONCERNS 

During the course of the inquest, the evidence revealed matters giving 
rise to concern. In my opinion, there is a risk that future deaths will occur 
unless  action  is  taken.  In  the  circumstances,  it  is  my  statutory  duty  to 
report to you. 

The MATTERS OF CONCERN are as follows.  

Whilst at the Royal London Hospital Jennifer had at least 6 episodes of 
sepsis from infected PICC lines. I heard evidence that these infections 
were contributed to by poor PICC line maintenance. and that the 
consultant colorectal surgeon raised concerns about the number of 
PICC line infections that Jennifer and other patients on the ward were 
getting. I heard some evidence about steps that had been taken but I 
was told that it was a nursing issue and I only heard evidence from a 
surgeon. I did not receive any written evidence about changes that 
have been made.  

6 

ACTION SHOULD BE TAKEN 

In  my  opinion,  action  should  be  taken  to  prevent  future  deaths  and  I 
believe that your organisation has the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date 
of this report, namely by 22 January 2024.  I, the coroner, may extend 
the period. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Your  response  must  contain  details  of  action  taken  or proposed  to  be 
taken, setting out the timetable for action. Otherwise you must explain 
why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the following interested persons: 

• 
•  Queens Hospital  

 (Jennifer’s daughter) 

And to: 

•  CQC 
•  HHJ Thomas Teague QC, the Chief Coroner of England & Wales  

I  am  also  under  a  duty  to  send  a  copy  of  your  response  to  the  Chief 
Coroner and all interested persons who in my opinion should receive it.  
I  may  also  send  a  copy  of  your  response  to  any  other  person  who  I 
believe may find it useful or of interest.  

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he  believes  may  find  it  useful  or  of  interest.  You  may  make 
representations to me, the coroner, at the time of your response, about 
the release or the publication of your response. 

9 

DATE                                           SIGNED BY ASSISTANT CORONER 
27 November 2023 

3

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Barking Havering and Redbridge University Hospitals NHS Trust (PDF)
Private & Confidential  
Melanie Sarah Lee 
Assistant Coroner 
Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

22 January 2024 

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

www.bhrhospitals.nhs.uk 
@BHRUT_NHS 

Dear Madam,  

Regulation 28 Report on the death of Mrs Jennifer Ruth Whinney 

Thank you for your Regulation 28 Report of 27 November 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 are: 

1.  Jennifer was referred to the colorectal specialist team at the Royal London Hospital and seen in 
late May. The witnesses were unable to give me the exact date of the appointment. Jennifer’s 
notes were not sent to the appointment with her. I heard that patient records at Queen’s Hospital 
are not electronic. Ward staff compile the notes which are sent physically with the patient if they 
attend any external appointment. I heard that no one person has responsibility for ensuring that 
the notes are sent. 

2.  Jennifer was articulate and understood her health problems well and so was able to provide the 

colorectal surgeon with her medical background. I am concerned that another patient may not be 
able to provide such a full and accurate history and that critical information may not be passed 
on. 

Trust’s response: 

1.  A review of the process for sending patients notes accompanying them to external hospital visits has 
been undertaken and we have identified gaps in the governance of this. The policy has now been 
revised internally and the updated policy, was approved at the Policy Ratification Group that took 
place today, on 22 January 2024. The changes include both implicit responsibility of handing the 
patients notes over to the nurse / medical escort or ambulance driver as appropriate, a checklist for 
the transfer of patients externally as well as a signature section to acknowledge receipt of the notes. 
A copy of this policy is included with this response for His Majesty`s Coroner`s kind review.  

2.  As part of the review of transfer of health records it has been noted that medical letters detailing 
Name, Date of Birth, NHS number, presenting compliant, medical history, medication history and 
reason for referral with contact details of medical team requesting the transfer as a minimum data set 
should be sent with the patient and is included in the checklist detailed above.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  The Trust is currently embarking upon its journey into digitisation of medical notes which should be 
completed in mid-late 2025. Once this is completed it is envisaged that the issue of medical notes 
being sent between hospital sites, that are also digitally enabled should be seamless; although it is 
recognised this is a lengthy timescale. 

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

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

Yours sincerely, 

Chief Executive
Response from Barts Health NHS Trust (PDF)
Trust Executive Office 
Ground Floor 
Pathology and Pharmacy Building 
The Royal London Hospital 
80 Newark Street 
London E1 2ES 

www.bartshealth.nhs.uk 

11th  January 2024 

Private & Confidential 
Melanie Lee 
Assistant Coroner 
Coroner Area Inner North London 
St Pancras Coroner’s Court 
Camley Street 
London 
N1C 4PP 

Dear Madam Lee, 

RE: Regulation 28 Prevention of Future Deaths Report: Jennifer Whinney 

I write in response to the inquest dated 17th November 2023 and the Regulation 28, Prevention of 
Future Deaths report to the trust dated 27th November 2023. I am sorry that the evidence of actions 
undertaken to reduce line infections at the Royal London Hospital (RLH) were not made available 
to you ahead of the inquest, but I understand 
 was able to explain our actions 
during the inquest. I write further to this discussion to lay out the actions that our clinical teams 
are continuing to take at the RLH. 

I note from the feedback from the trusts legal team, that you had been informed in November 2022 
that  a  Serious  Incident  (SI)  investigation  was  to  be  completed.  I  apologise  for  the  error  in  this 
information,  it  was  never  our  intention  to  investigate  this  through  the  SI  process  and  you  were 
misinformed about this. Our staff had correctly reported it on our incident reporting system (Datix 
ID 399559) noting the various line infections and it has been investigated locally through that route. 

Ms Whinney was admitted to the RLH on the 12th  July 2022 from Queens Hospital. Blood cultures 
were  taken from  her  PICC  line  on  the  12th  July  as  part  of  her  admission  assessments.  As  your 
findings  and  conclusions  have  documented,  these  came  back  positive  and  were  discussed  with 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 Microbiology for treatment advice on 13th  July. By the 15th  July she was showing the clinical signs 
of infection. As a result of this timeline, it was not felt that a comprehensive SI investigation was 
required. However, the team did recognise that there was learning and improvements to be made. 
We are sorry that after this time, Ms Whinney continued to experience a recurrence of line infections 
during  her  admission.  Despite  not  completing  an  SI  report,  the  clinical  team  did  investigate  the 
events that affected Ms Whinney, identified the source of her infection, and took actions to make 
improvements to the care of all their patients. 

In  the  summer  of  2022,  prior  to  Ms  Whinney’s  death,  the  surgical  nursing  leadership  team 
implemented an improvement programme for the management of lines. This included a number of 
workstreams including: 

•  Audit and performance - monitoring & feedback 
•  Training and education – aimed at both nurses and medical/ surgical professions 
• 
•  Ward cleaning checklists 

Improving staffing & retention - including nursing and ward housekeepers 

The introduction of a multi-disciplinary Line Infection Meeting provided a forum to share learning 
across  departments  as  well  as  the  introduction  and  oversight  of  a  robust  action  plan  started  in 
December 2022. This action plan continues to be monitored to this day with infection control practice 
being  regularly  audited  across  the  wards.  As  a  note  of  good  practice,  this  meeting  has  now 
expanded to be the Surgical Infection Prevention and Control (IPC) and Harm Free Care Forum, it 
thus incorporates a number of other aspects that all contribute to improving our patients safety and 
promoting  a  positive  experience  for  them  whilst  in  our  care.  Below  is  the  most  recent  section 
regarding the IPC action plan for reducing infections: 

Issue 

AIM 

Action 

Line 
Infections 

ANTT 

To ensure 
particularly long 
line infections 
are clear of all 
known 
infections 

To ensure line 
infection are 
prevented, 
ensure all wards 
are above 85% 

To monitor insertion and Line care on 
all wards - local audit 
Training initiated - planning OSCE 
several dates planned 
Data will be brought about how best 
and what to collect 
ANTT project to start 
To monitor insertion and Line care on 
all wards - Local Audit 
ANTT technique training being agreed 
5/5s (old) audit started on all wards 

Owner 

Ward 3E 

Staff 
involved 
All wards 
Nutrition 
team 

Measure of success 

Nutrition audits IPC 
audits 

Ward 3E 

All wards 
Nutrition 
team 

Nutrition audits IPC 
audits 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
   
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 Nutrition 

Review of MUST 
scores ensure 
all wards above 
85% 

To monitor compliance and actions 
across all wards 
Nutrition board 
Training 
MUST scores improving across all wards 
Symbiotix initiating on all wards -
hostess will order - to look at who else 
needs training 
All staff are reminded about the 
uniform policy in daily safety briefing. 

Noted during the strike the 3rd floor is 
very cold to bring to IPC board 
Compliance improving staff challenging 
poor practice 

Aim to achieve 
at least 90% 
compliance with  Ward manager to do spot checks on 
Tendable audit.  weekly 

Matron 

All Wards 
Matron 

Nutrition audits IPC 
audits 

All wards  All Staff 

Symbiotic audit results 
Tendable audit 
IPC quarterly audit 
results 

Minimise 
transmission of 
infection in the 
ward. 

Aim to achieve 
at least 90% 
compliance with 
Tendable audit. 
Aim to stay 
green for audit. 

10e 

Escalated to patient ambassadors who  Ward 
are responsible for cleaning. 
Still not 100% = Discussed ways in 
changing the schedule - rotating which 
half starts at 07:00am so the whole 
ward is focused on 
15 hours of funded cleaning is required 
extra on ward 3D 
Housekeeper to check  the store room  Ward 3D 
daily. 

Serco 

Tendable audit results 
IPC quarterly audit 
results 

All Staff 
House 
Keeper 

Tendable audit results 
IPC quarterly audit 
results 

Aim to achieve 
at least  90% 
compliance with  NIC to check if staff allocated to do the 
job has done the job 
Tendable audit. 
Review DSU cupboards - in place 
Aim to stay 
starting to use will feedback 
green for audit. 
improvements 

Educate staff the importance of the 
Aim to achieve 
at least 90% 
safety mechanism. 
compliance with  House keepers to check all the bays in 
Tendable audit. 
Aim to stay 
green for audit. 

the morning. 
Repeat audit later this month - create 
list of all non-safe sharps found in our 
areas 
Not consistent, DSU improving, wards 
still highlighting concerns 

Aim to achieve 
at least 90% 
compliance with  Check on weekly basis by ward manager  Matron 
Tendable audit. 
Aim to stay 
green for audit. 

Ward 
10E/ 

Chairs and tables to be cleaned daily 
flipped and cleaned underneath by 
ward hostess 
Met with hostess, supervisor and 
matron about key responsibilities and 
how to achieve this on each ward 

All wards  All Staff 

Housekeeper 

Tendable audit results 
IPC quarterly audit 
results 

Serco 

Tendable audit results 
IPC quarterly audit 
results 

Staff 
compliance 
with bare 
below the 
elbows 

High dust 
and low dust 
particularly 
in bay areas 

Equipment 
storage 
Orderliness 
and storage 
(i.e., clean 
utility and 
storage area) 

Safety 
mechanism 
of sharps 
bins not 
being used 
Overfill 
sharps bin 
Patients 
areas clean 
tidy. Chair 
cushions and 
tables clean 

 
 
  
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 All wards  All staff 

Tendable audit results 
IPC quarterly audit 
results 

Medication 
Management 

Aim to achieve 
at least 90% 
compliance with 
Tendable audit 
by IPC. 
Aim to stay 
green for audit. 

Moved IV medications into the locked 
medication cupboard. 
Drug prep area and storage shelving 
area to be included into the daily 
cleaning checklist. 
Medication trolley to be cleaned as 
required and checked daily 
NIC to check if daily temp record are 
complete on each shift. 
To ensure all drug trolleys are clean -
rota implemented on wards 
Include pharmacist to this meeting 

The work implemented by the nursing staff has resulted in improvements across the surgical wards 
with less line infections developing. This project has been presented at the RLH Senior Leadership 
Forum in June 2023 led by our Chief Executive. 

The  lines  themselves  were  put  in  place  in  our  Interventional  Radiology  (IR)  department.  The  IR 
service also have a quality improvement programme of work for reducing the risk of line infections 
and I attach their action plan for your information also. 

Issue 

Aim 

Action 

Owner 

Staff 
involved 

Measure of success 

Protocol discussed in safety huddles for 
2 weeks (documented in daily huddle 
minutes). Radiographers and Clinicians 
re-educated. Staff encouraged to 
challenge non-compliant members of 
team. 
Regular damp dusting allocation for 
staff and creation of cleaning record. 

Sister 

IR Team 

IR team fully compliant. 

IR IPCC 
Team 

IR team 

Cleanliness maintained 
and documented 

Re organisation of equipment’s in the 
non-critical / low risk areas. 

IR IPCC 
Team 

IR IPCC 
Team 

Items stored 
appropriately. Access 
for Domestics to clean 
all areas. 

Some staff not 
observing bare 
below the 
elbows. 

Staff 
following 
bare the 
elbow 
protocol. 

cleanliness 
maintained. 
Items stored 
appropriately. 
Access for 
Domestics to 
clean all 
areas. 

Dusts observed  Regular 
in procedure 
rooms 
Inappropriate 
and mix 
storage of 
items and 
equipment 
making it 
difficult to 
clean non-
critical / low 
risk areas 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 Rusted 
trolleys/ 
gratnells 

Damaged 
procedure 
table cushion 
and pillows 

All old and 
rusted 
trolleys/ 
gratnells 
replaced. 
All damaged 
procedure 
table cushion 
and pillows 
replaced. 
All 
equipment’s 
cleaned on a 
regular basis 
with "I am 
clean labels". 

Inadequate 
cleaning of 
some 
equipment 
(i.e., 
ultrasound 
machine, etc. 
Regular 
Task allocation 
for cleaning 
cleanliness 
equipment and  maintained. 
surfaces -
unclear 
responsibilities 
Doors of the 
procedure 
rooms are kept 
open when not 
in use 
Appropriate 
plan for 
management 
of visitors 
scrubbing in 
Donning area 
prone for 
splash 
contamination 

Donning 
trolleys 
relocated in 
all rooms. 

Protocol in 
place and put 
into practice. 

All doors kept 
closed at all 
times. 

Identify and replace trolleys/ gratnells 
that will need replacing. 

Sister 

IR Nursing  All old and rusted 
trolleys/ gratnells 
team 
replaced. 

Identify damaged procedure table 
cushion and pillows then replace. 

IR Team 

Senior 
Radiograp 
her 

All damaged procedure 
table cushion and 
pillows replaced. 

Creation of cleaning allocation and 
record for equipment’s. 

IR IPCC 
Team 

IR IPCC 
Team 

All equipment cleaned 
on a regular basis with 
"I am clean labels". 

Identification of responsibility owner 
and action maintained. 

Senior 
Radiograp 
her 

Regular cleanliness 

IR 
Radiograp  maintained. 
hers team 

Action mentioned in the safety briefing 
and morning huddle for 2 weeks. 

Sister 

IR Nursing  All doors kept closed at 
all times. 
Team 

Consult IPCC Team on creating a 
protocol/ management plan. 

Sister 

IR Nursing 
team 

Protocol in place and 
put into practice. 

Donning trolleys relocation for all 
labs/rooms and inform all staff. 

Sister 

IR Team 

Donning trolleys 
relocated in all rooms. 

The divisions continue to report progress each month to the hospitals IPC Committee chaired by 
the  Director  of  Nursing  (who  is  also  the  hospitals  Director  of  Infection  Prevention  and Control, 
DIPC) and this maintains oversight of the hospital acquired infections. 

In May and October 2023, the Clinical Lead Dietician and Lead Nutrition Clinical Nurse Specialist 
completed  teaching  sessions  at  forums  with  the  multidisciplinary  surgical  staff  (nursing  and 
surgical  professions). These sessions included teaching about practical tips to reduce Catheter 
Related  Blood  Stream  Infections  (CRBSI)  and  the  Surgical  Aseptic  Non-Touch  Technique 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 (Surgical ANTT) when managing surgical lines. Our Education Academy also runs an accredited 
surgical course for non-medical staff (nurses, midwives, and Allied Health Professionals) which 
includes training around line care, wound care and deteriorating patients. Furthermore, we have 
now updated our IPC statutory and mandatory training so that it is in line with the revised national 
standards. 

When all undergraduate medical students and junior doctors (Foundation year 1 and 2 trainees) 
join the trust, they undergo IV cannulation and venepuncture training which also includes ANTT 
training. This is part of their core teaching programme and again it follows trust guidelines. 

The  Deputy  Director  of  the  Barts  Health  Education  Academy  is  currently  in  the  process  of  re-
writing  the  ANTT  policy  with  our  microbiology  and  Infection  Prevent  and  Control  (IPC)  teams. 
When launched, this multi-disciplinary  policy  will  be embedded with training and  competencies 
that adhere to national guidelines. It is anticipated that the final version of this policy will be ready 
by the end of January 2024. 

I hope this provides you with the assurance that we take line management and infection control 
very seriously and that we do have improvement work underway across the Royal London Hospital 
but I would be very happy to discuss or clarify any of the above points if you wished. 

Yours sincerely 

Chief Medical Officer 

r

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