Asher was entirely dependent upon a complex package of care as a highly vulnerable ventilator dependent child. Evidence at inquest was that on numerous occasions he was not provided with the prescribed 2:1 care.

The care package, despite being described as one of the most complex and most expensive was not appropriately reviewed and there was no mandatory system of quality checks or formal review when there was a significant change in family circumstances. Quarterly reviews were not carried out without explanation.

The primary responsibility fell upon the family members, namely Asher’s parents, who were also responsible for other children in the family and employed as teachers. Concerns raised by the parents were not taken for discussion to case conference or professional’s meetings and essentially not followed up at all, leaving the situation in the house dangerous with an ultimately calamitous outcome.

There was a lack of scrutiny or reconciliation of Asher’s care package, which could have identified gaps that needed to be addressed. Training for the staff involved was unclear to the court and seemingly not in place or inadequate. A high turnover of staff was cited as one of the reasons, but this should have highlighted a need for increased training and scrutiny.

The court was advised that new structures would be in place by July 2022. The production of this report therefore has been delayed to give the opportunity for those systems to be in place and reported to the court.

1. Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of Eliot Harris in accordance with NSFT’s Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly. Quality audits undertaken following Eliot Harris’s death, show that observations are still not being carried out and recorded in accordance with NSFT’s most recent policy – more than two years following Eliot’s death. Not all staff have completed training with regard to carrying out of observations or have undergone and assessment of their competency to carry out observations.
2. On the night of Eliot’s death, a Nurse in Charge had not been allocated and members of staff were not allocated specific tasks – they were told to “muck in”, as a result there was some confusion as to who was responsible for specific jobs. The evidence at the inquest was not clear as to whether specific tasks are allocated to specific members of staff on Night Duty and whether and how a Nurse in Charge is appointed for each night’s rota.
3. Multi Team Meetings were not fully and properly recorded in the clinical records. At the inquest, evidence was heard there “is still some way to go” with regard to improving record keeping and for ensuring important matters such as rationale for decisions is fully recorded.
4. Eliot’s Care Plan was not up to date at the time of his death. At the inquest evidence was heard that although audits show there has been an improvement in completion of Care Plans, there “is still some way to go” and staff still need to be prompted to complete these.
5. Staff were reluctant to enter Eliot’s room following concern for his wellbeing. The evidence did not reveal what is now in place to ensure staff enter a patient’s room immediately if there are concerns for a patient’s welfare (having considered their (staff’s) own safety).
6. It is not clear from the evidence what is now in place to ensure that relevant and requested physical health checks are carried out. The process of ensuring health checks are carried out has not changed since Eliot’s death and remains a retrospective process.

Whilst at King’s College Hospital, Martha was not referred to the paediatric intensivists promptly. If she had been referred promptly and had been appropriately treated, the likelihood is that she would have survived her injuries.

• The bedside paediatric early warning score (BPEWS) system at King’s is currently still paper based, unlike the adult system. It was put to the coroner very forcefully by medical staff that, until the PEWS system moves to an electronic base as part of electronic recording of the paediatric records as a whole, monitoring and care of children may be sub optimal, with a higher risk of this sort of situation recurring.
• The King’s serious incident investigation identified that Martha’s care fell down between the paediatric hepatologists and the paediatric intensivists. Evidence suggests that it is the intention of King’s to improve the formal relationship between the hepatology and the paediatric intensive care departments, and to ensure that there is pro-active paediatric intensive care outreach. However, the intended programme has stalled, partly because of the pandemic. It seems that there needs to be an impetus for this to be re-started and to gain sufficient momentum to operate smoothly in the future. 

Response from King's College Hospital

Further reading

Sharing her story in the Guardian, Merope, Martha's mother, gives a heart breaking account of how Martha was allowed to die:

‘We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death (Guardian article)

Evidence from a wide range of clinicians who had cared for Sarah in March and April 2020 echoed each other. The clinician evidence revealed a common theme of lack of training, knowledge or experience on the part of physicians and medical staff (including GPs, pharmacist and acute hospital doctors) regarding the rare risk of sepsis following Early Medical Termination. The hospital trust accepted that at the time of Sarah’s death, there was confirmation bias in their thinking due to the Covid 19 pandemic and that other differential diagnosis were not considered in this case. Whilst the witness evidence was that Sepsis protocols were in place at both the GP surgery and the hospital trust, what is of particular concern is that none of the professionals who saw or spoke to Sarah were considering Sepsis in this case. Sarah was spoken to and seen by numerous medical professionals in both primary and secondary care but no sepsis protocols were initiated and the coroner found that the compounding delays in screening, diagnosis and treatment more than minimally contributed to a poor outcome in Sarah’s case.

For the Priory Hospital:

1. Record keeping: During the inquest staff confirmed that they record information about patients in two ways. On the electronic records and on handwritten handover sheets. During the inquest the evidence confirmed that different information was recorded on each. There are serious concerns that staff are recording information in two places and this creates a real risk, as materialised in Matthew’s case, that different information is recorded in each place and key information gets lost.

2. Record Keeping quality: There were numerous inaccuracies in Matthew’s medical records, eg his status was written as informal when he was formal, he was described as violent when he was not and was described as "she". Staff were unable to explain how that occurred. The investigation witness from the Priory thought there was an element of cutting and pasting into the records from another patient’s records. There are serious concerns about the accuracy of the clinical record at the Priory for what are some of the most vulnerable patients.

3. Risk Assessments: The inquest heard how all members of staff can update a Risk Assessment at any time. Despite this, and with clear evidence that Matthew was at risk of absconsion, his risk assessment was not updated over the weekend when the risk materialised. There are serious concerns about how risk assessments are completed, when they are completed, who completes them and whether they are updated in a timely and necessary manner by suitably experienced staff.

4. Serious Incidents: The inquest heard evidence that a previous absonsion over the courtyard fence in October 2019 had not prompted any review of the height of the fence and focussed on why the patient absconded ie to have a cigarette. There are serious concerns that the system of investigation in place at the Priory means critical lessons are not learnt at the appropriate time.

5. Courtyard Fence: A patient absconded over the courtyard fence during the inquest which indicates the courtyard area is not safe. There are serious concerns that an urgent review of the courtyard is required. In addition,evidence heard from a Dr that the fence was a ligature risk. Staff gave evidence that the courtyard in its current format with steps and a gradient on the grass bank was unsafe especially if a patient needed to be restrained.

For the Department of Health:

1. National guidelines for perimeter fences and security in acute mental health unit outside areas. The inquest heard evidence from a Professor, a specialist in safety in Mental Health settings, that it would be useful for there to be standard guidelines for the requirements of perimeter fences and security for outside areas in acute Mental Health units as no such guidance is in place. This would ensure the correct level of security for some of the most vulnerable patients whilst maintaining a therapeutic setting. 

1. There were excessive delays in handing over patients at hospital. The West Midlands Ambulance Service Serious Incident report found that there were excessive handover of patients at the Royal Stoke University Hospital, with some holding for over 4 hours. This impacted on the ability of the West Midlands Ambulance Service getting to patients. Oral evidence was given to the effect that this was a national issue, and not limited to the acute trusts within the West Midlands.

• Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen.
• The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death.
• The court heard that Barts NHS Trust had at least seven incidents relating to misplaced nasogastric tube since 2012.
• The court heard that the use of misplaced nasogastric tubes to administer liquids or medications continues to take place in Trusts across the country.
• The court heard that there is no unified approach to address the ongoing issue of avoidable deaths caused by using misplaced nasogastric tubes.

This report was sent to the Secretary of State for Health and Social Care, NHS England and Barts Health NHS Trust.

Misplaced nasogastric tubes

The life-threatening risk posed by the accidental misplacement of tubes that deliver food or medication to critically ill patients is a known patient safety issue. This was identified as a serious patient safety concern in the UK by the National Patient Safety Agency in 2005, by a formal Patient Safety Alert in 2011 and a further Patient Safety Alert in 2016. The Healthcare Safety Investigation Branch issued a report on the placement of nasogastric tubes in December 2020, making a number of safety recommendations in relation to this for NHS England, NHS Supply Chain, Health Education England and the British Society of Gastrointestinal and Abdominal Radiologists.

Frequency of this ‘Never Event’

This patient safety incident is formally classified by NHS England as a ‘Never Event’. This is a type of serious incident that is viewed as wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

NHS England routinely publishes data on the occurrence of Never Events. These figures highlight the annual frequency of the Never Event ‘Misplaced naso- or orogastric tubes and feed administered’ in England:

• 2020/21 - 34*
• 2019/20 - 25
• 2018/19 - 29*
• 2017/18 - 22
• 2016/17 - 26

*When accessed on the 10 March 2022 these figures were marked as provisional rather than final data.

Related reading

• Healthcare Safety Investigation Branch, Placement of nasogastric tubes, December 2020
• Tracy Earley, Improving safety with nasogastric tubes: a whole-system approach, 25 November 2019

• There was no clinical guidance or pathway within the Emergency Department of the hospital for patients presenting with suspected aortic dissection that should have included a directive to ensure that an ECG gated CT scan is carried out to exclude the possibility of such condition.
• When the Emergency Department were contacted by Ms Lumb on 5 January 2021 there was no mechanism by which staff were alerted to her genetic risk of aortic dissection leading to advice merely to contact her GP.

The Trust identified these shortcomings prior to the Inquest and have produced a guidance or pathway document for use in the Emergency Department for suspected aortic dissection called 'Management of Adult Patients with Suspected or Proven Acute Aortic Syndromes including Aortic Dissection'. Additionally, they produced a Standard Operating Policy to ensure that those patients identified with genetic conditions predisposing to acute aortic syndromes have an Emergency Heath Care Plan and a CPI flag.

The Coroner states that to prevent future deaths:

• all Trusts within England should be made aware of the circumstances of this case, and particularly the necessity to have in place a similar guidance or pathway document and standard operating policy. This is to be achieved via the NHS patient safety framework.

This report was sent to the South Tees NHS Foundation Trust and the Department of Health and Social Care.

Delays in recognition of acute aortic dissection

Missed diagnosis of aortic dissection is a known patient safety issue. Concerns about this were also raised in a Coroner’s report issued in 2021 following the death of Paul Satori, who died as a result of a dissecting aortic aneurysm following a misdiagnosis, having been discharged from hospital. The report into Mr Satori’s death also raised concerns about the guidance and awareness of aortic dissection at emergency departments. The Healthcare Safety Investigation Branch also published a report into this patient safety issue in January 2020.

Related reading

• The Aortic Dissection Charitable Trust – they aim to improve the diagnosis of aortic dissection and bring consistency of treatment across the whole patient pathway.
• Healthcare Safety Investigation Branch, Investigation into delayed recognition of acute aortic dissection, 23 January 2020.

Coroners have a duty to decide how somebody came by their death and also, where appropriate, to report about that death with a view to preventing future deaths.[1] [2] These reports follow a set template format and are issued by the Coroner to any person or organisation where, in their opinion, action should be taken to prevent future deaths. These reports are made publicly available online and the persons/organisations involved having a duty to respond within 56 days.

PFD reports relating to deaths in health and social care settings can help to identity what went wrong and the actions needed to prevent a similar incident reoccurring. They also may provide points of learning that are applicable beyond the organisation in which this took place which can inform wider system learning. On the hub we routinely add PFD reports that concern patient safety issues and learning.

Patient Safety Managers’ perspective

In their meeting last week, PSMN members shared their experiences about responding to PFD reports, highlighting that there are vastly different approaches to engaging with Coroners across NHS organisations. It was noted that responding to these reports can be quite complex, due to their sometimes wide and multi-organisational remit. There was also a discussion about how Coroners will consider whether to issue a PFD if they consider action has already been taken. In some cases, where a PFD is subsequently not issued, it was suggested that this could unintentionally result in learning remaining siloed in the organisation where the death occurred, rather than applied more widely.

Discussing how different Trusts approach responding to Coroners investigations and PFD reports, a number of key points of good practice were highlighted:

• Importance of establishing an effective, open, and transparent relationship with your local Coroner.
• Value of demonstrating to the Coroner the Trust’s awareness and action on specific issues through the use of thematic reviews, e.g., looking specifically at deaths by suicide.
• Using opportunities this process presents for learning and collaboration across a patient pathway, connecting across the Integrated Care System.
• Crucial role of debriefing after an inquest, ensuring learning is shared and that there is a rapid review of immediate actions.
• Providing the Coroner with information about Serious Incidents and previous relevant information where appropriate, to ensure transparency and help inform their considerations.
• Importance of providing support for staff in their attendance at Inquests so that they know what to expect.

PSMN members talked about the valuable role that PFD reports can play in highlighting patient safety issues that may not have previously had sufficient organisational understanding or commitment. They emphasised the importance of organisational commitment to these processes, with the need for senior leaders to attend inquests and understand the measures being taken to act on the Coroner’s findings.

They also considered how the processes currently in place may change as a result of the new Patient Safety Incident Response Framework (PSIRF) guidance on how to investigate incidents of unsafe care, and the importance of this being picked up in national policy and guidance, not just at a local level.[3]

Implementing actions and sharing learning

PFD reports provide a wealth of insights and learning; however, the key challenge remains ensuring that we utilise these to their full extent to improve patient safety and care. At Patient Safety Learning we believe that more could be done on at a regional and national level to ensure that NHS Trust’s are supported in implementing actions from PFD reports and sharing learning and outcomes more widely. In a previous blog, we suggested some key actions we believe are needed to help address gaps in the current system:

• Analysis reports – Integrated Care Systems carrying out annual thematic reviews of all PFD reports, Serious Incident reports and associated safety action plans, which could inform future commissioning safety action plans and Care Quality Commission insight.
• National oversight – establishing a clear system of oversight for monitoring the implementation and effectiveness of PFD report recommendations.
• Improve accessibility – creating a central repository for all PFD reports, Serious Incident reports and associated safety action plans in one database searchable by actions and themes.
• Standards – putting in place patient safety standards for Integrated Care Systems, with requirements on individual trusts, primary care networks and service providers to share learning from these reports.
• Annual report – publish an annual report on themes for learning and action from PFD reports and Serious Incident reports.

References

1. The Coroners. (Investigations) Regulations 2013, Part 7: Action to prevent other deaths, 2013.
2. Chief Coroner. Guidance No. 5: Reports To Prevent Future Deaths, Last revised 14 January 2016.
3. NHS England and NHS Improvement. Patient Safety Incident Response Framework, Last Accessed 5 March 2022.

1. During the inquest, evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a Mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions.
2. It was accepted that there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting. 

This report has been sent to The Huntercombe Group Limited and the Care Quality Commission.

1. There did not appear to be any national guidance or standards that directed or encouraged appropriate sharing of risk information and care plans with the local pharmacy. As a result, the pharmacy was unsighted on the fact that the treating psychiatric team had a safety plan involving Sam’s parents being responsible for handling and administering all medication. Had the pharmacy been aware of this plan, it is likely that they would either have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or General Practitioner.
2. A local protocol has now been introduced whereby the Cambridgeshire and Peterborough Foundation Trust’s Child and Adolescent Mental Health Service ensures that any pharmacy used regularly by their patients aged 16-17 are (where appropriate) advised of relevant care plans, as well as the responsible GP being so informed. This is now to be part of mandatory training for CAMHS prescribing staff and is to be discussed in the local Joint Prescribing Group to ensure better communication between the local NHS Trusts, G.P.s and local pharmacies. Accordingly, action has already been taken in the local area to prevent similar fatalities.
3. However, I am concerned that there is a risk of future fatalities if action is not taken at a national level to ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16-17, given that such patients may otherwise be able to obtain prescribed medication with which to overdose. 

This report has been sent to The Royal Pharmaceutical Society, The General Pharmaceutical Council, The Company Chemists’ Association and NHS England.

• The concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment. Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation. That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act.
• Although I understand that there is a long term plan to extend young people’s services to age 25, but I remain concerned about the ongoing situation, and that a young person today could be faced with the same challenges in finding support pending substantive treatment.
• I believe this concern is the combined responsibility of Cambridgeshire County Council and CPFT. These organisations may wish to consult in preparing their response to this report. The inquest heard evidence about the considerable delay in obtaining appointments for the Gender Identity Clinic, and about the shortage of availability for psychological therapies such as CBT. These are matters for policy and funding. This report will therefore be copied to NHSE and The Secretary of State for Health for information purposes only. 

On the 22 February 2021, he took an overdose of insulin; however, as his partner is a nurse, he didn’t attend hospital as she knew what to do. A PSIIR report and action plan was completed. Mr Stroud’s partner gave evidence, and it was clear from her account that she had been begging the care coordinator for Mr Stroud to have an appointment with the psychiatrist, which did not occur. From the evidence of EPUT, it was clear that Mr Stroud’s care coordinator did not make any referral to the MDT, despite his escalating psychosis. It was also clear from the evidence that none of the conversations with Mr Stroud’s care coordinator were recorded.

The action plan stated that one of the actions implemented since Mr Stroud’s death was that ‘all communications with the client should be recorded’.

Matters of concern:

That in all cases must go before the MDT, the evidence in this inquest made it clear that had Mr Stroud’s case been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death.

On the evidence from EPUT and the PSIIR it was clear that the care coordinator makes the decisions as to whether to refer a case to the MDT, in this case, no entries were made around the rational for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a care coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring. 

She acknowledged the problems faced by the ambulance service over the last two years, problems that have been compounded by the effects of the pandemic and delays in transferring patients into hospital emergency departments. She said she had also been informed that there have been plans in place to improve the responsiveness of the service, however from the evidence provided at this inquest it appears that problems still exist.

She asked to be provided with the following information:

• Confirmation of the action that will be taken to improve the response times of emergency ambulances.
• Confirmation of whether there are any plans to review the categorisation of elderly patients who suffer falls and are more likely to be affected by the risks associated with lengthy periods of immobility.

This report was sent to the Welsh Ambulance Service NHS Trust and the Health Inspectorate Wales.

• The Junior doctor Instructed to administer phenytoln did not know the required dosage and asked his more senior colleague for advice. The senior doctor's reply 15kmg/kg was heard by the Junior doctor as 50mg/kg resulting in administration of a significant overdose.
• This Is a readily foreseeable confusion which could apply in any hospital and could be avoided by use of clearer and less confusable means of communication and expression of number.

• Rebecca was at very high risk after discharge, and she did not have adequate medical review in between 6 July and her death on 19 July.
• the plan to see her once a week after discharge was inadequate.

In her report, the Coroner raised the following concerns:

1. In this case there was confusion as to whether on an inpatient transfer there should be a Form 2 to go alongside the Form 1 procedure. As well as clarifying this process with all providers concerned, consideration should be given that a clear, documented process is put in place for inpatient transfers so that all the involved understand clearly the situation and the decision made in relation to the patient.
2. Consideration should be given to ensuring that all care plans are time-specific so that dates of meetings of dates for tasks to be completed are set at the time of the meeting, so again expectations are managed and everyone knows exactly what the plan is and when actions will occur.
3. That the issue of inconsistent terminology when assessing risk is reviewed to ensure a consistent approach. In this case there were a number of different phrases and gradings used to determine the deceased's risk.
4. That consideration should be given to training and/or guidance issued for staff communicating with young persons by text or any means of social media.
5. Consideration should be given to reviewing whether there ought to be guidance issued when managing children who go out of area for psychiatric inpatient care and further guidance issued in the management of children when returning to their local area when they have been an inpatient out of area. Whether certain steps should be taken to ensure best practice and a consistent approach, for example, risk assessing, face to face meetings, robust care planning, parental involvement and how to best reintegrate back into the local area/team.

This report was sent to Avon & Wiltshire Mental Health Partnership NHS Trust, Dorset Healthcare University NHS Foundation Trust and NHS England.

• Hospital staff told the inquest that due to the reduction in staff numbers, they did not have enough time to carry out their expected tasks. As one healthcare assistant told the court, it was “impossible” to provide one to one nursing care to Mr Housby with the number of staff working on that shift.
• The court was told that since Mr Housby’s death, the problem of staffing shortages persists.
• Clifton hospital is a place to where patients – often elderly and vulnerable – are transferred for a period of rehabilitation, usually from an acute hospital setting. The usual aim is that following such rehabilitation, they can hopefully return to their homes, or perhaps be discharged to a suitable care home. However, the Coroner stated that these patients are being put at risk due to a shortage of staff.
• The Trust needs more support as they try to remedy this problem.

This report was sent to the Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool Clinical Commissioning Group/Fylde & Wyre Clinical Commissioning Group and the Department of Health and Social Care.

• There is no robust patient pathway to ensure that all patient factors relevant to the clinical indication for, and safety of, ERCP are identified in advance of the procedure and discussed with the patient.
• The lack of robust system for the recording of the vetting of the procedure, capturing information that has been considered as part of this process.
• Consent is not personalised, contrary to recommendations made by the European Society of Gastrointestinal Endoscopy in December 2019.
• A lack of accountability between professionals for ensuring robust vetting and consent.

This report was sent to Nottingham University Hospitals NHS Trust, the British Society of Gastroenterology, the Joint Advisory Group on GI Endoscopy and the European Society of Gastrointestinal Endoscopy.

• NICE Guidance NG121 last updated 25 April 2019 relates to intrapartum care for women with existing medical conditions or obstetric complications and their babies.
• Within this Guidance, whist there is reference at paragraph 1.17 to mode of birth for large-for-gestational-age babies, there is no definition of a large-for-gestational-age baby.
• There does not appear to be any national guidance or accepted definition of large-for-gestational-age, meaning that application of the Guidance is open to interpretation and variation depending upon an NHS Trust's own policies and guidance, and, in turn, the interpretation of obstetricians and other clinicians advising parents in anticipation of delivery modes.
• It is clear that NG121 is intended to provide guidance in relation to many potential scenarios which may impact upon care and decisions about mode of delivery. Application of section 1.17 includes consideration of shoulder dystocia and options for continuing labour or caesarean section, relevant to both the life of the mother and the baby. The uncertainty surrounding when section 1.17 should be relevant arises through the lack of a definition of a large-for-gestational-age baby.

This report was sent to the National Institute for Health and Care Excellence (NICE), Buckinghamshire Healthcare NHS Trust, the Healthcare Safety Investigation Branch, NHS England (National Maternity Lead) and the Royal College of Obstetricians and Gynaecologists.

In their response, NICE stated:

“During the development of NG121, the committee acknowledged that there is a lot of uncertainty around the diagnosis of large for gestational age. There is no standardised definition and clinical suspicion of large for gestational age, particularly during labour, is subjective and often inaccurate. While ultrasound estimation of fetal weight is likely to be more accurate, it is difficult to perform accurately during labour.

Given this uncertainty the committee felt it was important to give the woman balanced information to support shared decision making. The discussion between healthcare professionals and a woman with a baby suspected of being large for gestational age should focus not only on the potential risk of adverse outcomes for the woman and the baby, but also on the uncertainty around the diagnosis of a large-for-gestational-age baby and what it might mean for the woman and her baby if such problems did occur.

We believe that if the guideline were to provide a cut off it would be liable to convey inappropriate certainty, or reassurance if the cut off is not reached. As such, we do not believe that any action is required of NICE.”

•  No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Heath NHS Trust since 2018, there remains no requirement to utilise such a tool.
• Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient's welfare passed between the two teams but no targeted questions requiring clear factual responses were asked. Had such questions been put, a different outcome may have arisen.
• The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre.

 This report was sent to the Royal London Hospital, Department of Health and Social Care, Royal College of Surgeons and Royal College of Anaesthetists.