Prevention of Future Deaths reports · 2024
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 report | 28 Oct 2024 |
|---|---|
| Reference | 2024-0582 |
| Deceased | Kashim Ali |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | East London NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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
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.
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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