Prevention of Future Deaths reports · 2024

Kashim Ali

Regulation 28 report to prevent future deaths, reference 2024-0582, written 28 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report28 Oct 2024
Reference2024-0582
DeceasedKashim Ali
CoronerIan Potter
Coroner areaInner North London
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedEast London NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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

Prevention of Future Deaths Report 
Kashim ALI (date of death: 21 May 2024) 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 

Chief Executive Officer 
East London NHS Foundation Trust 
Robert Dolan House 
Trust Headquarters 
9 Alie Street 
London 
E1 8DE 

1 

CORONER 

I am Ian Potter, assistant coroner, for the coroner area of Inner North London. 

2 

CORONER’S LEGAL POWERS 

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

3 

INVESTIGATION and INQUEST 

On 28 May 2024, an investigation was commenced into the death of Kashim 
Ali, then aged 56 years. The investigation concluded at the end of an inquest 
heard by me on 21 October 2024 at Poplar Coroner’s Court. 

The inquest concluded that Mr Ali died from natural causes. The medical 
cause of death was: 

1a cardiac arrest 
1b hypertensive heart disease 
II schizophrenia, hyperkalaemia, type 2 diabetes mellitus  

4 

CIRCUMSTANCES OF DEATH 

Mr Ali was detained under section 3 of the Mental Health Act 1983, on 
Millharbour Ward at Mile End Hospital. His detention was for the purposes of 
providing treatment in relation to his longstanding diagnosis of ‘treatment 
resistant schizophrenia. 

On 21 May 2024, shortly after 09:00, Mr Ali was noted to be asleep in his 
bed. A few minutes later, he was noted to be totally unresponsive. Emergency 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 procedures were followed, but attempts at resuscitation were not successful. 
Mr Ali died as a result of cardiac arrest. 

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 could occur unless 
action is taken. In the circumstances, it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows: 

1)  Any National Early Warning Score (‘NEWS2’) should always be 
escalated. However, during Mr Ali’s time on Millharbour Ward he 
achieved a NEWS2 score on more than one occasion, which was not 
escalated to the nurse in charge for review. 

While this was not a causative factor in Mr Ali’s death, I consider that it 
creates significant risk for other patients in future, if not addressed. 

2)  During part of his on Millharbour Ward, Mr Ali was on one-to-one 

observations, requiring him to always be within the sight of a dedicated 
member of staff. Following Mr Ali’s death, it transpired that during this 
period of observations, designated members of staff were noted to 
preoccupied with the use of their personal mobile telephones at times, 
and on one occasion, the designated member of staff was sat on a 
chair with their back to Mr Ali’s door. 

While this was not a causative factor in Mr Ali’s death, I consider that 
such practices undermine patient safety and would place future 
patients at considerable risk. 

3)  The Trust noted, during its own serious incident investigation, that the 
quality of record keeping in relation to Mr Ali’s observations was not 
always accurate. Given the key role that accurate record-keeping 
plays in patient care within any healthcare setting, I formed the view 
that this also creates significant risk.  

I heard evidence that the Trust is taking the above matters seriously and 
that they are going to be addressed at Board level. However, it was 
acknowledged that there was still work to do to address the risks 
identified. 

6 

ACTION SHOULD BE TAKEN 

In my opinion, action should be taken to prevent future deaths and I believe 
that you have 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 
the report, namely 9 December 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 Chief Coroner and the following: 

1. 

 – Mr Ali’s next of kin 

2.  Care Quality Commission 

I am also under a duty to send the Chief Coroner a copy of your response. 

The Chief Coroner may publish either or both in a complete or redacted or 
summary form. She may send a copy of this report to any person who she 
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 by the Chief Coroner. 

9 

Ian Potter 
HM Assistant Coroner, Inner North London 
28 October 2024

Responses

1 response 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 East London NHS Foundation Trust (PDF)
Office of the Chief Medical Officer  
Trust Headquarters  
Robert Dolan House  
5th Floor  
9 Alie Street  
London E1 8DE  

Private & Confidential 

For the attention of HMC Ian Potter 
Bow Coroner’s Court 
Bow Road 
London E3 3AA 
By email only: 

9 December 2024 

Dear Sir, 

RE: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

1.  This is a formal response to your Regulation 28 report issued on 28 October 
2024 where you set out concerns relating to the care of the late Mr. Kashim Ali 
whilst he was under East London NHS Foundation Trust’s (the ‘Trust’s’) care. 

2.  I understand that at the inquest into Mr. Ali’s death, you heard evidence which 

gave rise to the following concerns: 

Concern 1 – Failure to escalate NEWS2 scores 

Concern 2 – Inappropriate staff practices 

Concern 3 – Inaccurate record keeping at times 

3.  I am therefore writing to reassure you and the family of Mr. Ali that the Trust has 
carefully reviewed these issues as highlighted in the Regulation 28 Report and 
has either taken or plans to take the actions outlined below. 

RESPONSE 

 
 
 
 
 
 
 
  
 
 
  
 
 
 
 
 
 Concern 1: Failure to Escalate NEWS2 Score 

4.  I was concerned to hear that on more than two occasions while on Millharbour 
Ward, Mr. Ali achieved a NEWS2 score which was not escalated to the nurse 
in charge for review. 

5.  The  Trust  takes  the  monitoring  and  escalation  of  NEWS2  scores  extremely 
seriously,  as  it  is  a  key  part  of  ensuring  patients’  physical  health  is  closely 
managed and responded to appropriately. I have set out below the processes 
in place which are relevant to this concern. 

Staff Training 

6.  All in-patient nursing staff across the Trust are now required to attend a two-
day  physical  health  training  course.  This  course  includes  comprehensive 
instruction  on  NEWS2,  its  significance,  and  the  appropriate  escalation 
procedures. This  training  is  mandatory  and  forms  part  of  the Trust’s  ongoing 
commitment to ensure that inpatient clinical staff have the knowledge and skills 
required to respond effectively to physical health concerns. 

7.  In addition to the initial physical health training, NEWS2 training is also included 
in the Trust’s annual mandatory online training programme. This ensures that 
all inpatient nursing staff are refreshed on the key aspects of NEWS2, including 
recognising deteriorating physical health and the correct process for escalating 
concerns to senior staff. Completion of this training is monitored. 

Nursing Handover Process 

8.  The nursing handover process has been standardised in Tower Hamlets and is 
set to be rolled out across other directorates in the Trust to ensure that the care 
needs and risks for each patient are clearly communicated at the start of each 
shift. This includes a thorough review of physical health issues, with a particular 
emphasis  on 
frequency  and  appropriateness  of  physical  health 
observations,  including  NEWS2  scores. The  handover  is designed  to  ensure 
that  all  staff  are  aware  of  the  specific  needs  of  each  patient,  including  any 
concerns related to their vital signs or deterioration. 

the 

9.  Every  ward  across  the  Trust  also  hold  a  daily  MDT  meeting,  where  any 
concerns regarding physical health observations, including NEWS2 scores, are 
raised and discussed. This provides an additional layer of oversight to ensure 
that all potential issues are flagged early and responded to appropriately. 

 
 
 
 
 
 
 
  
 
 
 
 10. A further safeguard is in place with the the directorate’s inpatient unit’s midday 
huddle, where a report is generated from the RIO system to identify any patient 
who has a NEWS2 score of 3 or above (3 or above being the level that requires 
escalation) within the previous 24 hours. If such a score is identified, the ward 
teams’  interventions  and  escalation  process  are  reviewed  to  ensure  that 
appropriate  actions  have  been  taken.  This  process  is  recorded  for  audit 
purposes  and  provides  a  clear  trail  to  confirm  that  physical  health  concerns 
have been addressed. 

11. As part of the the directorate’s inpatient unit’s new handover process, there is 
now  a  specific  training  tool  for  the  Nurse  in  Charge,  which  covers  the 
importance of monitoring and escalating physical health observations, including 
NEWS2  scores.  Section  11  of  this  tool  directly  addresses  the  importance  of 
overseeing physical health observations and ensuring they are carried out and 
acted upon. Each Nurse in Charge is required to confirm they have reviewed 
and  understood  this  process,  ensuring  that  they  are  fully  aware  of  their 
responsibilities in managing and escalating NEWS2 scores. 

Concern 2: Inappropriate Staff Practices 

12. I was concerned to learn about the inappropriate staff practices you set out in 
your Regulation 28 notice. The Trust takes these matters very seriously, and I 
would like to outline the steps we are taking to address the concerns raised and 
to reinforce our expectations regarding staff conduct and clinical practices. 

Disciplinary Action for Non-Compliance  

13. The Trust has thoroughly investigated the incident and is following established 
disciplinary  procedures  for  each  staff  member  who  failed  to  comply  with  the 
required observation standards in relation to Mr. Ali's care. Where evidence of 
non-compliance  with  the  Trust’s  policies  or  failure  to  meet  expected  clinical 
standards has been identified, appropriate action is being taken in line with our 
disciplinary  framework.  This  is  to  ensure  accountability  and  to  prevent 
recurrence of such lapses in care. 

 
 
 
 
 
 
 
  
 
 
 
 
 Reinforcement of Mobile Phone Policy 

14. We  recognise  that  the  inappropriate  use  of  personal  mobile  phones  by  staff 
during clinical shifts can be detrimental to patient safety and the quality of care. 
In  response  to  this  concern,  the  Trust  has  reviewed  and  updated  its  mobile 
phone  policy  to  establish  clear  guidelines on  the  acceptable use of  personal 
phones  within  clinical  settings,  with  the  effect  that  staff  are  completely 
prohibited  from  using  personal  mobile  phones  during  shifts.  This  policy  is 
designed to ensure that staff remain fully engaged with their patients and the 
clinical environment, minimising distractions and maintaining focus on patient 
care. 

15. To further ensure that these issues are being addressed at the local level, the 
frequency  of  visits  by  a  lead  Nurse  or  a  Matron  on  night  shifts  has  been 
increased to twice a month from once a month for three months. These visits 
are focused on maintaining high standards of care and ensuring that all clinical 
practices, including the monitoring of physical health observations, are being 
consistently followed. As part of these visits, any use of mobile phones by staff 
is specifically observed to ensure compliance with the updated policy. These 
increased visits are also an opportunity to address any concerns directly with 
staff and to reinforce the Trust’s expectations regarding clinical standards. 

Concern 3: Inaccurate Record Keeping at times 

16. The  Trust  fully  acknowledges  the  importance  of  accurate  and  timely  record-
keeping  in  delivering  safe  and  effective  care. The  concerns  raised  regarding 
inaccurate or incomplete records in relation to Mr. Ali’s observations are taken 
very seriously, and I would like to outline the steps we have taken to address 
this issue and improve the quality of documentation across the Trust. 

17. As the Trust PSII set out, work is progressing on introducing an e-observations 
system which will prompt staff to enter both their observations and engagement 
with the patient (rather than just the location of the patient), and this will be time-
stamped. On the app each patient’s observation care plan will be linked to their 
record of observation. This ensures continuity of care. Any reviews in level of 
observations  will  require  an  entry  to  be  made  verifying  the  escalation  and 
decision making process. 

Amendment to Ward’s Daily Spot Check Audit 

 
 
 
 
 
 
 
  
 
 
 
 
 18. In response to the concerns raised, the Directorate has amended the daily spot 
check audit process on all wards, including Millharbour Ward, to ensure that the 
quality  of  patient  records  is  closely  monitored.  The  daily  spot  check  now 
specifically  includes  a  detailed  review  of  the  records  kept  during  patient 
observations,  including  physical  health  observations  and  any  clinical  actions 
taken in response to changes in a patient’s condition. This enhancement to the 
audit process is designed to ensure that any gaps or inaccuracies in record-
keeping are identified early and addressed promptly. 

19. The amended spot check audit now includes an evaluation of the following key 

areas: 

•  Accuracy of recorded observations: Checking that vital signs, including 
NEWS2  scores,  are  accurately  documented,  with  any  changes  in  the 
patient’s condition clearly reflected in the records. 

•  Timeliness  of  documentation:  Ensuring  that  records  are  completed  in 
real-time or as close to the observation as possible, rather than being 
left incomplete or delayed. 

•  Clarity and completeness of entries: Verifying that all entries are clear, 
legible, and provide sufficient detail regarding the patient’s condition and 
any actions taken by staff. 

20. This more thorough approach to daily spot checks will be overseen by the Unit 
Matron and ward managers to ensure that accurate and complete records are 
always  maintained. Any  issues  identified  during  the  audits  will  be  escalated 
immediately,  and  targeted  interventions  will  be  put  in  place  to  address  any 
deficiencies in record-keeping practices. 

Updated Observations and Therapeutic Engagement Policy 

21. The  Trust  has  just  introduced  an  updated  Observations  and  Therapeutic 
Engagement  Policy  (ratified  27th  November  2024).  The  updated  policy  now 
includes  additional  material  covering  (1)  expected  standards  of  engagement 
and  documentation  following  period  of  enhanced  observations  (2)  expected 
standards of documentation including process to be followed for observations 
not  undertaken  (3)  Trust  wide  agreed  ‘change  ideas’  to  improve  therapeutic 
engagement  and  observations  and 
in 
Documentation  training  as  part  of  the  observation  competency  training  staff 
must complete. 

the  addition  of  Honesty 

(4) 

 
 
 
 
 
 
 
  
 
 
 
 Ongoing Training and Support 

22. The Trust  recognises  that  accurate  record-keeping  is  not  only  crucial  for  the 
continuity of care but also for accountability and auditing purposes. As such, 
the Trust  is  committed  to  reinforcing  these  standards  through  regular  audits, 
continuous  training,  and  a  robust  system  of  checks  to  ensure  that  patient 
records are always completed in a timely, accurate, and thorough manner. 

23. The Trust will continue to review and enhance its processes for record-keeping 
and auditing as part of our ongoing commitment to improving the quality of care 
we provide. By ensuring that all documentation is accurate and up to date, we 
can  better  support  clinical  decision-making,  improve  patient  outcomes,  and 
ensure that our practices remain aligned with the highest standards of care. 

Conclusion 

24. I hope this response provides sufficient reassurances to you and to the family 
of Mr. Ali about the additional learning that has taken place at the Trust because 
of his sad death. 

25. I would like to offer my sincere and heart-felt condolences to Mr. Ali’s family at 

this difficult time. 

Yours sincerely, 

Chief Medical Officer 

Chief Executive: Lorraine Sunduza 
Chair: Eileen Taylor

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