Harold Penny

Tameside Hospital NHS)

NHS Foundation Trust

Chief Executive Office

Silver Springs

Tameside General Hospital {~
Ashton-Under-Lyne

OL6 SRW

Our ref: |
Your ret

Date: 16 January 2015

Private & Confidential
Mr J S Pollard

HM Senior Coroner
Coroner's Court

1 Mount Tabor Street
Stockport

SK1 3AG

Dear Mr Pollard

Harold Penny (Deceased)

! write further to your letter dated 24 November 2014 enclosing a Regulation 28 Report issued
at the conclusion of the inquest touching the death of Harold Penny, which took place on 21
November 2014. | am, of course, very sorry that you felt the need to issue this Report. |
hope to be able to address the concern, as set out in Section 5 of the report, to your

satisfaction in this letter.

i There seems to be no system in place to require the Radiology Department either
to rectify the situation themselves if that is possible, or to urgently report back to
the treating clinicians in a case where, for example, they find that a urinary
catheter has become displaced and is causing a blockage.

The Trust recognises that in a large number of patients radiological imaging plays a
pivotal role in both diagnosis and treatment. | entirely agree that it is essential that
there is a robust system in place at the Trust which confirms the responsibilities of the
referring clinician, the radiologist and the radiology department.

Work is being undertaken in this area at the Trust as part of the Sign up to Safety

campaign which was launched by the Secretary of State for Health on 24 June 2014
with a mission to strengthen patient safety in the NHS. A draft ‘Radiology Requesting
and Reporting Policy’ has been produced by the Trust and is currently going through

our governance procedures.

A Results Governance Steering Group (RGSG) was also developed in October 2013
and is one of ten project teams that report to the Tameside Hospital Patient Safety
Programme Board (PSPB) as part of the ‘Keeping patients safe and reducing harm’
programme. The RGSG met for the first time on 4 November 2014 and is concerned
with ensuring that the Trust has clinical and operational processes to adequately
support effective results governance. The scope of this group is to ensure that
effective results governance processes are in place to ensure the timely recognition
and escalation of abnormal clinical results. The 2014-2015 objectives of this group
specifically include improving the standards of results governance from both a report
and service delivery perspective. The group has completed an initial review of
processes and is now meeting monthly to ensure implementation and continuous

improvement.

The draft radiology policy, referred to above, will be reviewed in the Results
Governance Steering Group meeting in February 2015. The finalised policy will be
brought to the attention of staff by Lead Consultants and will be circulated by way of an
‘all acute’ email and will be available on the Trust intranet. Staff will receive notification
that a new policy has been uploaded to the intranet which they will then be required to

familiarise themselves with.

The radiology policy, referred to above, recognises that it is essential that radiologists
and all reporting practitioners are provided with the relevant clinical information in order
to prioritise and interpret radiological investigations. This, together with reliable and
timely communication of results, forms the basis of an effective imaging service. The
policy will reinforce the responsibilities of referring clinicians in requesting and acting
upon radiological findings in a timely fashion. The purpose of the radiology policy is to
provide a clear framework in which this system will operate within the Trust.

The vast majority of radiology investigations are given a formal report that is
transcribed on to RIS (Radiology Information System) and, once authorised (approved
by the radiologist), is held as a permanent record. Authorised reports are automatically
transferred to both EPR (Electronic Patient Record, referred to as ‘Lorenzo’ at Mr
Penny's inquest) and PACS (the Picture Archiving and Communications System)
where they can be read hospital wide and acted upon.

The radiology requesting and reporting policy confirms that all radiological
investigations constitute part of the permanent patient record, regardless of whether it
is formally reported by Radiologists or not. It is mandatory that a record of the
investigation, its findings and subsequent action is fully and consistently documented in
the patient's notes. The Radiologist provides a report which forms part of the patient's
health records unless there is a documented agreement that the images will be
reviewed by a referring clinician and reported on by them. The policy will define that a
formal radiological report will be issued for any radiological investigation, regardless of
its nature, if specifically requested by the referring clinician and providing there is
sufficient radiological expertise locally to do so.

| understand that one of the issues explored at Mr Penny’s inquest was radiology report
turnaround times. The Trust will incorporate recommendations from the RCR
Guidelines to ensure robust systems and processes are incorporated into the final
document. At the Trust the objective is to report GP, in-patient and Emergency

Department examinations the same day. Where there are urgent findings (where
medical evaluation is needed within 24 hours) the expectation will be that these are
reported within four hours, the time frame depending on the nature of the imaging
findings. Priority is given to inpatients, urgent requests and unexpected significant
findings. The Trust's objective is to document Significant radiological findings and
ensure they are communicated in a timely and unequivocal fashion. The Trust is
reviewing its IT infrastructure to ensure this support is in place.

A small proportion of imaging tests will demonstrate significant findings that are
unexpected or warrant early action. In Mr Penny’s case, the detection of a displaced
urinary catheter was unexpected and warranted early action. | confirm that it is the
responsibility of the Radiologist, or the performing healthcare practitioner e.g.
Consultant/Advanced Practitioner or Sonographer, to ensure that the nature and
Significance of abnormal findings are clearly stated in the report. | understand that in
Mr Penny's case the CT scan report produced on 19 June 2014 did clearly confirm
significant distension of the bladder and the misplaced catheter. Advice was given that
this should be deflated and a new catheter inserted. If the radiologist recommends
further investigation or action this should be communicated effectively to the referring
Clinician. Again, our policy will ensure that all responsibilities are clearly defined.

As confirmed above, a significant unexpected finding, such as the displaced urinary
catheter, will warrant specific action. The urgency of the action will depend on the
nature of the abnormality. | can confirm that our radiology policy, discussed above,
classifies significant findings as:-

| Critical (red category). Life threatening abnormality where clinical assessment
and action is required immediately. Immediate verbal communication with the
referring clinician is mandatory at the Trust in the case of critical findings. This is
the responsibility of the reporting radiologist or a designated deputy.
Communication should be with the Consultant / GP in charge of the case or an
alternative senior member of the team. Occasionally communication will be with
a junior team member or ward nurse. The policy confirms that it is essential that
the significance of the findings is clearly stated and further instruction given
where relevant. A record of the communication will be recorded in the
radiology report, including the name of the person receiving this information. A
record of the communication in the patient’s health records is also mandatory
and should be dated, timed and legibly signed. This is the responsibility of the
person to whom the results are communicated, i.e. the referring clinician, ward
doctor or GP. In cases of critical findings the policy will specifically direct that an
attempt should be made to contact a senior member of the referring team where

possible.

2 Urgent (amber category). Where clinical evaluation is required within 24 hours.
Radiology to be reported within 4 hours. The Trust has also recommended to the
Radiology Department that where there are urgent findings that they make use
of voice recognition software to ensure that the report is given priority typing. The
radiologist can then verify them instantly and the report is immediately available
electronically to the referring clinician.

3 Unexpected. A finding of this nature will usually not be expected by the referrer
or patient. The speed of action and assessment will depend upon the nature of
the finding. It may require urgent communication of the findings by the issue of a
short code on CRIS (Computerised Radiologist Information System) indicating
there is an unexpected finding on the report. Following that alert a medical
secretary will then inform the referrer via fax. The Trust has a safe faxing
protocol which will be referenced within the policy.

The Radiologists also have a responsibility to ensure that copy reports are sent, where
appropriate, to GPs, MDT co-coordinators or specialist nurses, for example lung cancer
nurses. This responsibility helps to minimise the risk of important findings not being
followed up and acted upon.

As set out above, the policy that we are in the process of ratifying, places a great deal
of responsibility with the Radiologists within the Trust. However, it is important to note
the responsibilities of the referring clinicians also. It is their responsibility to ensure that
they have in place a robust system to enable tracking and follow up of all radiology
reports. One of the focus areas of the RSRG is to review frameworks for tracking and
follow up of all radiology reports and ensure these are robust. Once received, reports
should be legibly signed, dated and filed in a permanent patient record with a clear
indication of any action taken following receipt of the report. It is the responsibility of
the referring clinician to ensure this takes place and individual systems in place will be

subject to regular audit.

Summary

The requesting practitioner has responsibility for:-

a: Ensuring that they are logged in under their name before an electronic request is
made.

2, Recording the discussion of the case between a Radiologist and a referrer in the
patient’s record if a request for imaging is declined to ensure that the record
contains a balanced summary of the discussion. This will include the name of
the Radiologist, the reason for declining the investigation and any other
recommendations offered.

3: Ensuring that the minimum data set for radiology referrals is included on
requests.

4. Responding promptly to a request for further information regarding a request for
radiological investigation.

5. Discussing the case with a Radiologist if asked to do so by the on call
Radiographer.

6. Ensuring the investigation, findings and subsequent action is recorded in the

patient record.

Reading the report of every radiological investigation they generate.

Ensuring that the patient is aware of the follow up arrangements so that results

are communicated in a timely fashion.

9. Ensuring that they have in place a robust system to enable tracking and follow
up of all outstanding radiological reports.

10. Signing and dating a radiology report and ensuring it is filed in the permanent
patient’s record with a clear indication of any action taken.

CON

11. | Recording the result of an ‘out of hours’ investigation in the patient record when
the on call Radiologist communicates this verbally.

The Consultant in charge of the patient is responsible for:-
1. Ensuring that the person interpreting an unreported radiological investigation is

qualified to do so.

The Radiologist involved has the responsibility for:-

. Ensuring that the referrer is informed that a request for imaging has been declined.

2. Ensuring that the reason for declining a request is documented in the common
section of CRIS with the appropriate attendance number.

3. Ensuring the nature and significance of abnormal findings are clearly stated in the
report, and any recommendations are clear and unequivocal.

4. Immediate verbal communication of critical findings to the Consultant/GP in charge
of the case or an alternative senior member of the team/practice and ensuring a
record of the communication is recorded in the radiology report, including the name
of the person receiving the information.

5. Recording the result of an out of hours investigation in the patient record wherever
possible or communicating the result to a member of the referring team.

The Radiology Department has responsibility for:-
1. Ensuring a robust system for the communication of Significant radiological findings

using the specified communication process as described above.

| do hope that | have addressed your concern and that | have reassured you of the
work that the Trust is currently undertaking in relation to the requesting and reporting of
radiology at the Trust in order to prevent the recurrence of a similar set of
circumstances in the future.

Should you have any further questions arising from the contents of this letter, please do
not hesitate to contact me. | am again sorry that your investigation into this death
caused you such significant concern to issue a Regulation 28 Report but | hope that

you are now reassured.

Yours sincerely

Karen James
Chief Executive