Abdirahman Afrah

Group Executive Office 
Ground Floor 
Pathology and Pharmacy Building 
The Royal London Hospital 
80 Newark Street 
E1 2ES 
Group Chief Medical Officer 

Date:18th July 2025 

–  Abdirahman  Afrah 

Dear Miss Persaud 

Prevention 
Your Reference – 2025-0245 

of 

Future  Death  Report 

Thank  you  for  your  Regulation  28  Report  concerning  the  tragic  death  of 
Abdirahman  Abdirizaq  Afrah.  We  extend  our deepest  condolences  to  his  family 
and recognise the importance of learning from this case to prevent future deaths. 

We  take  the  matters  of  concern  you  have  raised  with  the  utmost  seriousness. 
Below we set out actions already taken and those planned by Barts Health NHS 
Trust to address each point. 

The responses will be delivered in an updated ‘Left Without Treatment’ (LWOT) 
policy  (drafted  and  waiting  formal  review  and  stakeholder  approval)  and  an 
immediate  safety  bulletin  which  will  be  actively  shared  to  all  staff  groups  in  the 
Emergency Department. This will be shared electronically, and daily at in-person 
handovers  to  reach  as  many  staff  as  possible  to  effect  immediate  change  in 
practice. More detail is included in each section. 

The inquest heard that waiting times to be seen in Majors A&E at Newham 
Hospital  could  sometimes  be  between  9  to  14  hours.   Many  patients  are 
unable  to  tolerate  such  long  waits  and  leave  the  department  before  being 
seen. 

And 

*Jones S, Moulton C, Swift S, et al Association between delays to patient admission from the emergency 
department and all-cause 30-day mortality 
Emergency Medicine Journal 2022;39:168-173. 

 
 
 
 
 
 
 
 There  was  no  timely  triage  of  major's  patients  by  the  medical  team,  to 
ensure that those with the greatest potential of clinical decline are picked up 
quickly  and appropriate  investigations  commenced  at  an  early  stage. 
Without  such  frontloading  of  care,  patients  like  Abdirahman  who  might 
compensate right up to the point of collapse might be missed again.     

We have grouped these together as prompt  triage and ‘queue management’ go 
together with managing clinical safety in the emergency department. 

Long waits for any part of the patient journey are harmful and a poor experience. 
The  Royal  College  of  Emergency  Medicine  describes  the  harm  this  causes  in 
emergency departments* across the country.  We recognise this pressure in our 
department and that the underlying causes are multifactorial. Tackling long waits 
in the emergency department must have a whole-hospital response. 

The underlying issues are multifactorial, and we appreciate that long waits in the 
Emergency Department (ED) are the responsibility of the whole hospital to fix. 

Front Door and Triage 

We acknowledge the importance of early investigations in the patient journey. We 
undertake Rapid Assessment and Treatment (RAT) for patients presenting to the 
emergency department. This involves oversight and review by a resident doctor 
trained in the rapid assessment process.   At the time Abdirahman attended ED 
there would have been a single resident doctor working at the front door, so it is 
not possible to see every patient, but focus on cases raised by the triage nurse 
and targeting high risk patients on the screening assessment; RAT would have 
been the opportunity for Abdirahman’s first contact with a doctor . A chest X-ray 
would likely have been requested at this stage. 

Since August 2024, enhanced RAT training has been added to the induction of all 
resident doctors above foundation level and there is an active program to train all 
regular locum doctors in this process. This has increased our capacity to front-load 
tests and investigations throughout the day and night.  

There is an active quality improvement project ongoing which is aimed at improving 
processes  for  initial  assessment  of  patients  self-presenting  to  the  emergency 
department. The aim of this project is to decrease initial assessment waiting times. 
In addition, there is a focused area for high-risk patients where there is increased 
availability of the RAT Dr to respond to queries, review patients, request imaging 
and start treatments. The project includes introducing easy to follow assessment 

*Jones S, Moulton C, Swift S, et al Association between delays to patient admission from the emergency 
department and all-cause 30-day mortality 
Emergency Medicine Journal 2022;39:168-173. 

 
 
 
 
 
 pathways  and  an  education  package  for  all  nursing  staff  involved  in  initial 
assessment.  

Appropriate Place of Care 

Since October 2024 we have introduced a new ‘Fast Lane’ for assessment and 
treatment of walk-in emergency patients. The provision of an area with consultation 
rooms and dedicated ED doctors has resulted in decreased waiting times for this 
group  of  patients  and  improved  performance  against  the  4-hour  target  for  non-
admitted emergency patients from 50 to 65%. 

Over the past 12 months we have expanded our physical space in the Same Day 
Emergency Care (SDEC) area. We have also merged our ambulatory medical and 
emergency medical clinical teams working in this area, with additional increase in 
clinical staffing numbers. This has allowed suitable patients to be directed to the 
most suitable clinical area and as a result  this has reduced waiting times in the 
emergency department and improved patient experience. For example, patients 
presenting with chest pain follow one of the key pathways that can be assessed 
on  SDEC,  as  well  as  easing  the  pressure  on  emergency  patients  in  the  main 
department. 

ED Workforce Review & Expansion 

We  have  successfully  recruited  to  all  of  our  consultant  vacancies  in  the  last  6 
months  and  will  have  a  significant  increase  in  senior  residents  managing  the 
department  from  August  2025.  This  increase  in  senior  decision  makers  will 
enhance the safety in the department overall, with senior oversight over the queue 
and  earlier  definitive  decision  making  in  the  patient  journey  with  a  resultant 
reduction in waiting times.  

Care Beyond the Emergency Department & Flow 

We  frequently  experience  patients  waiting  a  long  time  in  the  emergency 
department for an inpatient bed. There are several improvement projects ongoing 
within the hospital to improve flow which have resulted in a significant improvement 
in the number of patients being discharged before 5pm to enable greater flow from 
ED to the ward which in turn reduces congestion in ED prior to the evening which 
is a very busy period  

*Jones S, Moulton C, Swift S, et al Association between delays to patient admission from the emergency 
department and all-cause 30-day mortality 
Emergency Medicine Journal 2022;39:168-173. 

 
 
 
 
 
 
 
 
 Recognising  that  a  functioning  ED  and  manageable  waiting  times depend  on  a 
whole hospital response, ‘action cards’ have been created which give actions to 
ED nursing and medical teams, hospital site management and speciality teams to 
manage long waits in ED. Actions include direct referral to speciality teams to see 
patients, accessing escalation areas, triggering contact with Trust managers and 
directors to manage workload across the Group. 

Oversight & Queue Management 

In the last 12 months we have implemented several electronic tools that provide at 
a glance prompts to senior medical and nursing staff. These are designed to draw 
attention to patients who need immediate action or should be seen sooner. 

Automatic vital sign frequency and  ‘red heart’ alert flag. This provides a 
visual cue to medical and nursing staff if a patient’s observations are outside 
normal range and need repeating.  

Notification of VBG and ECG requiring review. This gives a visual flag that 
an ECG has been taken and requires review and signing by a doctor. The VBG 
flag has been implemented in the past two months and mitigates many of the 
risks of the old paper system. When results are available electronically, they 
are flagged with a red sign in the patient’s location and must be signed when 
acknowledged. 

Acuity flags and concerns. We have introduced a customised acuity rating 
system for patients falling into different risk groups to draw attention and give 
priority.  These  are  those  who  have  infectious  diseases,  those  who  are 
vulnerable  (through  physical  or  other  disability,  hearing  or  communication 
issues),  mental  health  presentations  and  those  who  have  clinical  concerns 
requiring prompt response (sickle cell, crisis cancer with immunosuppression, 
sepsis). 

When the doctor called Abdirahman the following afternoon, she did not have  all 
the relevant clinical information to hand. She was not aware of the compensated 
metabolic acidosis. It is unlikely that she advised Abdirahman of the importance of 
returning to the hospital. It is foreseeable that patients may be reticent to return to 
A&E, because of the lengthy waits, so doctors making the call to patients who have 

*Jones S, Moulton C, Swift S, et al Association between delays to patient admission from the emergency 
department and all-cause 30-day mortality 
Emergency Medicine Journal 2022;39:168-173. 

 
 
 
 
 
 
 
 
 left, should be fully informed about the clinical condition and risks. The risk of not 
returning should be made very clear.   

Whilst  we  acknowledge  that  we  are  already  doing  more  than  many  emergency 
departments by calling patients who have not waited, we are keen to do more.  

The doctor who called Abdirahman was aware the blood test was abnormal and, 
on this basis, advised that he should return for an assessment. 

The  new  LWOT  policy  will  be  clear  on  how  to  advise  patients  regarding  their 
options for assessment and treatment including advice on the risks of not receiving 
care to enable patients to make an informed choice.  

Abdirahman  was  17  years  old.  He  declined  to  return  to  A&E.  There  was 
no direct discussion with a responsible parent about the need to return to 
A&E.   

In Abdirhaman’s case, his parent was on the call with him when the attendance at 
his GP practice was discussed. However, we must consider the actions needed 
when dealing with adolescents. 

We  recognise  that  those  under  the  age  of  18  are  children  by  law  and,  where 
appropriate, a responsible adult or person with parental  responsibility is likely to 
need to be contacted. However, adolescents are special group that deserve due 
consideration.  It  would  not  be  appropriate  to  make  a  blanket  rule  to  disclose 
information about attendance to a parent or guardian when in some cases this may 
not be in the best interests of the adolescent. 

In view of this case, we are urgently reviewing our left without treatment (LWOT) 
policy to include a section around the special consideration for under 18s that have 
LWOT  where  a  senior  decision  maker  must  be  involved  when  making  a 
management plan. 

We have included  a section in our  current staff safety bulletin that any patients 
under 18 who have left without treatment must be escalated to a senior clinician in 
real time so that the appropriate response can be decided upon and implemented. 

When  Abdirahman  stated  that  he  would  be  seeing  his  GP  later  that 
afternoon, he asked for the relevant results to be sent to the GP. Neither the 
results,  nor the  discharge  summary  were  sent  to  the  GP  in  time  for  the 

*Jones S, Moulton C, Swift S, et al Association between delays to patient admission from the emergency 
department and all-cause 30-day mortality 
Emergency Medicine Journal 2022;39:168-173. 

 
 
 
 
 
 
 appointment. The inquest heard that the A&E doctor  did not know how to 
share such information with the GP.   

On  this  occasion  no  discharge  letter  was  completed.  Even  with  advances  in 
electronic patient records, discharge letters are not shared rapidly as they are not 
intended to share very urgent clinical information. 

Discharge letters for patients within the East London Patient Record footprint are 
received after around six hours of leaving emergency department. This is to avoid 
serial  letters  being  generated  after  any  changes  are  made  (with  results  or 
prescribed medicines). 

Patients  out-of-area  (e.g.  those  visiting  London,  registered  to  a  GP  practice 
elsewhere), have discharge letters printed and posted manually by administrative 
staff in daily batches. 

More  urgent  electronic  messages  can  be  sent  to  GPs  via  Accurx  (an  NHS 
messaging platform) which works for most practices both in and out of area.  

Since August 2024 we introduced specific administration time for junior doctors in 
ED  to  check  results.  During  this  process  all  resident  doctors  have  been  using 
Accurx  to  contact  patients  and  GP  practices  and  thus  the  use  of  this  form  of 
communication has increased significantly. 

Discharge  letters  should  still  contain  useful  clinical  tests  and  investigations, 
especially if action may be needed from the recipient. Direct phone calls may be 
needed where written messages are not fast enough 

We have emphasised the importance of including sufficient clinical information via 
the  most  appropriate  means  when  managing  patients  who  have  left  without 
treatment in our current staff safety bulletin and will formalise instructions in the 
LWOT policy, so this is accessible to all current and future staff. 

Yours faithfully,                                                                                              

Chief Medical Officer 

*Jones S, Moulton C, Swift S, et al Association between delays to patient admission from the emergency 
department and all-cause 30-day mortality 
Emergency Medicine Journal 2022;39:168-173.