Elvon Morton

Trust Headquarters  
Executive Offices 

Ground Floor                                 

Pathology and Pharmacy Building 

The Royal London Hospital                    

 80 Newark Street 
London 
E1 2ES 

Our ref:   ID406705 
Your ref: 20918500 

Date: 09 July 2024 

Private & Confidential 

East London Coroners Court 
Queens Road 
Walthamstow 
London 
E17 8QP 

Dear HM Coroner, 

Thank you for your letter dated 13 May 2024 following the inquest of Mr Elvon Paul Randolph 
Morton detailing concerns arising from the evidence presented and inviting the Trust to consider 
the implementation of changes to reduce the risk of future harm or death.   

The Prevention of Future Death report has been reviewed at the Whipps Cross Hospital Board 
and Divisional Board to agree actions that will have an impact across the Barts Health group.  

This response is based on information provided by: 

, Clinical Lead, Emergency Medicine 

, Clincal Director for Speciality Medicine 

, Clinical Director Surgery Division  

Your concerns and our response  

1.  Documentation  of  key  stages  in  Mr  Morton's  care  was  poor  or  non-existent. 
Critical decisions on; mental capacity, best interests, the choice of sedation, the 
amount  of  drug  administered,  the  method  of  administration  and  the  timing  of 
treatment 
administration  were  not  clearly 
contemporary documentation is essential to preserve patient safety. ln this case 
the  lack  of  clear  documentation  meant  that  some  clinicians  were  unaware  that 
Elvon was sedated, whilst others were ignorant of the fact that he had declined 
treatment. 

ln  multi-clinician 

recorded. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The teams acknowledge that the documentation at all levels is suboptimal. There was 
no  consultant  documentation  or  contemporaneous  documentation  on  Millenium  (the 
electronic healthcare system) or on paper. The consultant’s remote access had lapsed 
so they were unable to access the system, but they did not arrange a retrospective entry 
when access was available. The documentation of discussion with intensive care unit 
(ITU) specialist registrar (SPR) and Accident and Emergency (A&E) consultant on call 
indicates brief response to what was a much more detailed discussion. 

A  specific  induction  programme  has  been  formulated  for  the  A&E  which  specifically 
covers  themes  such  as  the  mental  capacity  act,  contemporaneous  documentation 
including  emergency administered drugs  with rationale,  sedation and also escalation. 
The  induction  programme  will  be  delivered  and  evidenced  retained.    A  specific 
presentation  relating  to  the  Mental  Capacity  Act  (MCA)  its  implementation  in  practice 
and the  wider considerations  will  be  delivered within the teaching  programmes  for  all 
grades within A&E. 

All doctors starting with ITU receive written pre-induction material to orientate them to 
the  service.  This  is  supplemented  with  face-to-face  departmental  induction.  The 
induction material has been updated to state very clearly the need for contemporaneous 
documentation  of  clinical  decision  making  wherever  possible.  Where not  possible the 
documentation should reflect a retrospective entry with reasons why the entry had to be 
deferred. 

The speciality medicine team have a teaching programme and induction of all levels of 
Internal  Professional  standards  and  appropriate  contemporaneous 
staff  on 
documentation.    Training  will  also  be  provided  to  all  staff  grades  to  ensure  that  they 
understand how to assess mental capacity and the application of deprivation of liberty 
safeguards (DoLS). 

Teams will ensure that consultants on call confirm that they have remote access to the 
electronic  healthcare  record,  this  will  eliminate  the  risk  that  documentation  is  not 
completed in relation to critical decisions. 

2.  Witnesses  blamed  poor  documentation  on  workload,  specifically  an  influx  of 
acute  patients  into  the  resuscitation  bays.  Despite  this,  no  evidence  was 
presented that any attempt was made to mitigate this pressure by, escalating the 
matter to the site manager, nor did the on-call ED consultant find it necessary to 
come into  the  unit. These  actions  tend  towards  a "coping  culture"  inconsistent 
with patient safety. 

The  Trust  are  supportive  of  staff  that  are  increasingly  managing  high  numbers  of 
complex and acutely unwell patients.  In this case, doctors sought and were provided 
with advice from a consultant on call.  The consultant on call will attend to perform certain 
procedures (in line with the Royal College of Emergency Medicine guidance). With the 
benefit of hindsight, consultant presence would have provided support for the trainees. 

 
 
 
 
 
 
 
 
 
 The clinical review group agree that a wider discussion needs to take place to review 
WXH A&E working patterns and consultant cover, these discussions are complex and 
will likely take place over the next 12 months in conjunction with other improvement work 
being  undertaken  to  manage  patient  flow  within  the  hospital.  Risks  in  relation  to  ED 
pressures  including  overcrowding  and  resus  capacity  are  reflected  on  the  WXH  risk 
register. 

3.  The  decision  to  sedate  Mr  Morton  was  flawed.  The  lack  of  contemporary 
documentation  impeded  an  effective  coronial  investigation  and  review  of  that 
clinical  decision.  ln  the  absence  of  clear  and  reasoned  evidence  of  decision 
making, weight must be attached  to evidence heard  that, Elvon's; size, sex and 
race triggered a heightened response by hospital staff to his agitation, leading to 
security officers being called. lt was in this febrile atmosphere that the decision 
to utilise rapid tranquilisation, a simpler and faster process than anaesthesia and 
intubation, was made. 

There  is  permanent  security  presence  in  the  emergency  department  (ED)  to  protect 
patients and staff from people who pose a risk to themselves and others.  The decision 
to seek  security  support  is based  on  a  dynamic risk  assessment  and  whilst  the  Trust 
acknowledge  the  lack  of  documentation  support  was  sought  to  maintain  the  patient’s 
safety to support clinical management and risks associated with leaving the department 
against clinical advice.  

The  Trust  accept  and  apologise  for  the  fact  that  the  documentation  available  to  the 
coroner  impeded  investigation  and  decision  making.    The  clinical  view  from  the  ITU 
mortality  and  morbidity  meeting  and  additional  post  inquest  clinical  review  is  that, 
considering  the  degree  of  metabolic  derangement,  this  patient  would  likely  still  have 
suffered a cardiac arrest on induction of anaesthesia, and clinical outcome most likely 
to  have  been  the  same  as  that  consequent  to  cardiac  arrest  secondary  to  the 
administration of sedation. 

For assurance and complete clarity, the new rapid tranquilisation guidance which in the 
process of being recently updated is applicable to the whole of Barts Health has a very 
clear wording at the top “This guidance is not to be used in the hypoxic, hypovolemic or 
septic  patient  or  in  one  in  which  intubation  as  opposed  to  rapid  tranquilisation  is 
required”.    This  will  ensure  decision  making  is  senior  and  clearly  documented  if  and 

when the guidance cannot be followed in cases where there is sound clinical justification 
to do so. 

4.  A failure in governance at the Trust meant that this case was not identified as a 
serious  incident.  This  omission  gives  rise  to  a  concern  that  future  deaths  may 
follow  due  to  an  inability  on  the  part  of  the  trust  to  identify,  reflect  upon,  and 
remediate sub-optimal practice. 

 
 
 
 
 
 
 
 
 
 
 
 This  patient’s  death  on  7  December  2022  was  unexpected  and  was  reported  as  an 
incident via the Datix reporting system but it was not presented for multidisciplinary team 
(MDT) discussion as a serious incident. The fail safe whereby a mortality and morbidity 
meeting triggers Serious Incident Review Assurance Panel (SIRMAP) discussion did not 
happen because although learning was identified the outcome was not felt to have been 
due to failures in care. Following a prompt from HM Coroner via the legal team, the case 
was presented to SIRMAP in July 2023 and the panel identified learning but did not find 
that the outcome could have been altered in this case.  

Since  November  2023,  WXH  have  been  in  the  process  of  implementing  the  Patient 
Safety Incident Response Framework. There is a very clear directive that unexpected 
deaths need to be reported via Datix and presented at Patient Safety Incident Review 
Meeting (PSIRM) so that an MDT decision can be made in terms of the correct learning 
response. In cases where care is thought to have led to the patient’s death a PSII will 
be  undertaken  (these  investigations  can  take  up  to  6  months  to  complete).  In  other 
cases,  an  After-Action  Review  or  SWARM  huddle  (where  staff  ‘swarm’  to  review  an 
incident) will be undertaken, these need to be completed within 12 weeks. In other cases, 
the  PSIRM  chair  will  request  that  the  case  be  presented  to  M&M  and  the  outcome 
reported back to PSIRM.  

WXH have very carefully considered PFDs issued by the coroner in conjunction with late 
submissions  and  the  impact  this  has  on  families,  HM  Coroner  and  ensuring 
preparedness for inquests. Steps have been taken to ensure that specialities have early 
sight of inquests. This will ensure that cases are reported via Datix, presented to PSIRM, 
learning  responses  and  other  key  documentation  are  submitted  in  a  timely  manner 
(including statements). A proposal has been prepared to recruit a learning from deaths 
lead,  their  primary  responsibility  would  be  to  drive  improvement  with  stakeholder 
engagement including families, MEs, and coroners. 

The Trust deeply regret the concerns raised by HM Coroner and the impact the inquest findings 
will have had on the  patient’s family. Arrangements will be made to share this letter with the 
patient’s  family  and  an  offer  extended  to  them  to  meet  with  senior  clinicians  to  discuss  any 

questions, concerns or additional learning and improvement that the Trust should implement in 
light Mr Morton’s death. If you have any queries, please do not hesitate to contact me. 

If you have any queries, please do not hesitate to contact me. 

Yours sincerely 

Group Chief Medical Officer 
Barts Health NHS Trust

Parliamentary Under-Secretary of State for    
Mental Health and Women's Health Strategy   

From 

39 Victoria Street   
London   
SW1H 0EU   

21 June 2024 

Our ref: PFD – 24 – 05 – 13 – MORTON 

HM Coroner Graeme Irvine 
East London Coroner’s Court 
Queens Road 
Walthamstow 
London  
E17 8QP 

By email: 

Dear Mr Irvine,  

Thank  you  for  the  Regulation  28  report of  13  May  sent  to  the  Department  of  Health  and 
Social Care about the death of Elvon Paul Randolph Morton. I am replying as the Minister 
with responsibility for patient safety.       

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Morton’s 
death, 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.  

The report raises concerns over a lack of documentation and poor medical decision making 
in Mr Morton’s care and failures in governance at the Trust.  

In preparing this response, Departmental officials have made enquiries with NHS England. 
The  department  is  advised  that  the  matters  of  concern  raised  are  primarily  local  and  for 
Barts Health NHS Foundation Trust to address, who confirm they are in receipt of this report. 
The report provides a further opportunity for the Trust to reflect and assure itself that it has 
acted  on  all  the  learnings  to  be  taken from  Mr Morton’s  death.  It  is  vital that  lessons are 
learnt collectively, and changes are made to reflect where things have gone wrong, which 
is essential to ensure the NHS provides safe, high-quality care.    

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

Yours sincerely,