Mnayea Al Basman

NHS)

Royal Free London
NHS Foundation Trust

Royal Free London Hospital Group,
Pond Street,
London
NW3 2QG
Phone:

Private and Confidential

His Majesty's Assistant Coroner Mr lan Potter
St Pancras Coroner's Court

Camley Street

London

N1C 4PP

Via Email

28 January 2025
Dear Sir,

Re: Regulation 28: Prevention of Future Deaths report - Mnayea ZMF Al Basman (date
of death: 25t" March 2024)

We write to you in response to the Regulation 28: Prevention of Future Deaths report following
the Inquest into the death of Mnayea ZMF Al Basman.

We would like to reiterate our sincere condolences to the family of Mr Al Basman for their loss.

The Royal Free London NHS Foundation Trust has carefully considered the matters of
concern raised in the Regulation 28 Report. We note that the two consultants involved in the
case (a colorectal surgeon and a renal physician) submitted written statements and gave
evidence at the inquest but the Trust was not joined as an interested person to the inquest
proceedings. We are grateful for the opportunity to respond to the matters you have raised.
We would like to start by assuring you that the Trust had undertaken 3 safety review meetings
as part of our routine governance processes before the inquest. These had identified areas
of learning and included information that may have assisted you in relation to the areas of
concern listed in this report.

You raised several matters of concern and we respond to each of them below:

“1) The consultant colorectal surgeon was not in the hospital over the weekend of
23/24 March 2024; however, he was able to be contacted if the need arose. The
consultant surgeon noted the following matters in relation to the care provided to Mr Al
Basman over that weekend: a further CT scan could have been indicated, particularly
given issues with Mr Al Basman’s drain, albeit there was nothing to indicate that any
scan was needed on an urgent basis...”

The patient was being treated for intra-abdominal sepsis with intravenous antibiotics and was
showing steady improvement in the infection markers throughout the day prior to cardiac
arrest. He had been reviewed that day by a consultant renal physician who examined him
and discussed his care with the consultant colorectal surgeon in a phone call. The patient had

NHS)

Royal Free London
NHS Foundation Trust

also undergone 2 prior CT scans on the 16" and 17 March, both of which showed no
evidence of anastomotic rupture.

The case was reviewed at the Royal Free Hospital Patient Safety Response panel on 10th
April 2024. A Learning from Death Review was presented and discussed at the Colorectal
Mortality and Morbidity Meeting on 7 June 2024, followed by a presentation at the Royal Free
Hospital's Mortality Review Group. The internal reviews concluded that an urgent CT at the
time of deterioration would not have significantly impacted on the patient's ultimate outcome.

There are well-established arrangements in place that should emergency surgery be required,
the on-call surgical team at Royal Free would have taken responsibility for the patient.

“some entries in the clinical notes appeared falsely reassuring...”

A foul-smelling discharge was noted at the surgical drain removal site. The resident medical
officer reviewed the patient and administered further antibiotics. The consultant colorectal
surgeon was not contacted but on subsequent review has stated that further CT scanning
would not have been indicated overnight.

As part of ongoing education for junior medical and ward nursing teams, we will emphasise
the critical importance of contacting the responsible consultant should there be any change in
a patient's condition.

“the physiotherapist who saw Mr Al Basman on the morning of 24 March 2024, noted
that he appeared to be ‘declining’ but there was no evidence that this was escalated
this to someone within the healthcare team...”

Therapy teams often use the term “declining” or its variations to indicate a patient's
unwillingness to participate in therapy, rather than a description of a deteriorating medical
condition. On the day in question, the physiotherapist did not assess Mr Al Basman as the
patient declined treatment. However, the physiotherapist did note that Mr Al Basman appeared
more unwell, but there is no documentation confirming that this observation was
communicated to the nursing or medical team.

To ensure appropriate identification and escalation of deteriorating patients, the PPU therapy
team will participate in training on ‘Management of a Deteriorating Patient’.

“there was a degree of insufficient professional curiosity on the part of some
clinicians who saw Mr Al Basman...”

Medical documentation indicated that the patient experienced mild chest distress and
abdominal distension, suggesting a potential for deterioration. In view of this, a plan is in place
to ensure the PPU medical and nursing staff complete ‘Management of a Deteriorating Patient’
training. This training includes a review of recognising early signs of changes in the patient
condition, methodology for clinical assessment and management, and a review of the
framework to communicate concerns.

“...there should have been a plan in place overnight to more closely watch Mr Al-
Basman overnight on 24/25" March...”

A review of the medical notes acknowledges that while the patient’s observations on the
evening of 24 March 2024 did not initially raise significant concern, the reduction in urine

INHS

Royal Free London
NHS Foundation Trust

output in a dialysis-dependant renal patient would not have necessarily been an important
marker of clinical deterioration. However, as part of an overall clinical assessment,
deterioration in urine output should have been acknowledged and may have prompted an
earlier medical review and closer monitoring.

While this may not have changed the ultimate outcome for the patient, it would have
constituted best practice. As a result, an action plan has been implemented to support
nursing and medical teams in identifying and appropriately responding to early signs of
deterioration. j

“2) Based on the above, the consultant surgeon formed the view that Mr Al Basman’s
clinical presentation should have led to the consultant being informed and consulted,
but it did not.”

We acknowledge that the patient’s condition appeared to deteriorate in the evening of 24"
March 2024 and that closer monitoring and escalation to the consultant surgeon could have
been implemented. However, three separate internal multi-disciplinary reviews concluded that
there was no clear indication for an overnight- CT scan and that it was highly unlikely to have
changed the course of the patient's management even if it had been performed.

“3) A number of the notes/records in relation to the care provided to Mr Al Basman,
particularly over the weekend of 23/24 March 2024, lacked detail”

We acknowledge that the documentation over the weekend of 23 — 24"" March 2024 regarding
discussions concerning the patient’s condition could have been more thorough. This is
reflected in an action plan for nursing and medical staff to improve assessment and
documentation of potentially deteriorating patients.

Given that the events preceding Mr Al Basman’s death have not been the subject of
an internal investigation, | received little, if any, reassurance that these matters have

been addressed.

The Trust is committed to fully cooperating with all coronial investigations and keeps its
processes for doing so under continual review. We hope this letter reassures you that Mr Al
Basman’s death was investigated and presented at the Royal Free Hospital’s Patient Safety
Event Review Panel (PSERP), a Learning from Death (LfD) review was conducted and
presented at the Colorectal Mortality & Morbidity meeting and was also presented at the Royal
Free Hospital’s Mortality Review Group (MRG) prior to the inquest. Additionally, there has
been a careful review of his care again as a result of your report.

The Trust is committed to learning from Mr Al Basman’s tragic death and continuously
improving patient safety. We will actively monitor adherence to the ongoing improvement plans
and the Trust’s action plan is set out below. This will be monitored by the PPU Divisional
Quality & Safety Board and the Clinical Performance and Patient Safety Committee.

NHS)

Royal Free London
NHS Foundation Trust

Action

Concerns
raised

Action / Response

Owner

Failure to
escalate to
consultant

e Education to Nursing and
Resident Medical Officer
(RMO) teams regarding
how and when to escalate
to consultant

e Shared learning in divisional
and consultant meetings

e Review PPU Escalation
Process

PPU Medical &
Nursing Leads

Training and
audit log of
education

programme

Presentation at
divisional
meeting

Recognition of
deteriorating
patient

e Education programme to
Nursing, Therapies and
Resident Medical Officer
teams to include:

o Simulation training run
by Royal Free Patient
at Risk Team (PAART)
medical and nursing
staff in the
management of a .
deteriorating patient

o Revision on the
importance and
accuracy of fluid
balance with clear
escalation policy

o Reiterate process of
identification patients at
risk of deterioration and
process for escalation
of care to HDU/ITU

PPU Medical &
Nursing Leads

June
2025

Training and
audit log

Policy on
deteriorating
patient

Documentation

e Education to nursing
regarding clearly
documenting conversation
with doctor including what
items were discussed and
the plan

e Reiterate Standardised
template clinical workflow

e Develop Documentation
quick guide for staff

reference

PPU Nursing
Lead

June
2025

[Trang and
audit log

Documentation
quick guide

INHS)

Royal Free London
NHS Foundation Trust

4. [Seven-day e Reiterate of out-of-hours/ |PPU Medical] June
services review/ | sickness cover for Lead 2025 Presentation at
doctor coverage consultants PPU medical
plan ; advisory
° Reiterate of the Gonater
responsibilities of primary
admitting doctor speciality
5. Communication PPU Medical &|June
e Create written standardised |Nursing Leads |2025 eas,
process of board rounds enc ardise)
which will help with early ak iar
identification of deteriorating
patients Documentation of
e Review of consultant — education on
RMO communication in and consultant-RMO
out of hours. communication

We will be sending a copy of this letter to North Central London Integrated Care Board.

If you would like any further information about any part of this letter, please do not hesitate to
contact us.

Yours sincerely,

Medical Director
Royal Free Hospital
Royal Free London Group NHS Trust

Chief Executive Officer,
Royal Free Hospital
Royal Free London Group NHS Trust