Bryan Whitby

ob

Central Manchester University Hospitals NHS}

NHS Foundation Trust
Room 217
Medical Directors Office
Trust Headquarters
Manchester Royal Infirmary
Oxford Road
Manchester, M13 9WL

14 May 2015

Miss J Kearsley

Area Coroner
Coroner's Court

1 Mount Tabor Street
Stockport SK1 3AG

Dear Miss Kearsley

Re: Bryan Herbert WHITBY (deceased)

Thank you for your letter of 25 March 2015. | instructed the clinical team to review the case and have
set out the answers to the points noted in the Regulation 28 notification below.

The deceased had been unwell for some time and had a history of Chronic Kidney Disease (CKD)
Stage 3. He had been referred for a CT scan but the GP Practice were not aware of the date of the

scan or that this would take place on 03 May 2014.

The Directorate Manager for Radiology has advised that Radiology would not normally inform a GP of
scan dates or send the results to them unless they were the referring Clinician. The scan was

requested on 29 April 2014 by FY Surgical Registrar, in the lower gastrointestinal (Gl)
clinic.
gations/procedures a patient has had as part of

The GP does need a complete picture of what investi
unicated to the GP in a letter from the Specialist

their secondary care episode but this would be comm
once all investigations were complete.

Blood tests taken on 02 May were not escalated by the GP or the Pathology Laboratory, and the scan
on 03 May went ahead while he was still receiving Metformin medication. The Radiologist carrying
out the scan did not have access to his blood resuits from 02 May and simply went off the results from

the GP referral some time ago.

The Radiology Lead for Trafford Division has advised that their policy at that time was to check the
most recent blood results within three months. The blood results reviewed were the most recent at
the time they were checked and had been taken on 24 April 2014, which was nine days prior to the

scan.

At this time, the eGFR result was 71 and there was no indication in the information the Radiology
Department received that there was any concern over Mr Whitby’s renal status. The Surgeon
recorded on the referral form for the CT scan with contrast that Mr Whitby’s eGFR was 71 and that he
was taking Metformin for his Type Il diabetes. These eGFR results did not cause concern as they
were well within the Royal College of Radiologists and NICE guidance for giving contrast which is 50

for intravenous contrast and 60 for stopping Metformin.

The Radiology Department were unaware of the further blood tests taken at the GP Practice on 02
May 2014. Whilst these results were available on the same day on the Electronic Patient Record

(EPR) the Radiology staff would not have routinely looked for further results at that time unless they
had been informed that there had been a change in Mr Whitby’s condition. Given the short time
between Radiology booking and scanning Mr Whitby, they did not look again on the system.

As a result of this incident, the Radiology Department have reviewed their practice in relation to the
timing and assessment of renal function prior to intravenous contrast administration. Following this
review they have implemented a process to check for any later results prior to giving contrast
injections for CT scans as a routine protocol for all patients with known CKD.

| am sorry but there is no record of who requested further blood tests on 06 May 2014.

On the morning of 06 May 2014, Mr Whitby’s blood tests from 02 May 2014 (eGFR 40 and Creatinine
148), were checked by the GP and the drop eGFR and magnesium, and the raised Creatinine were
noted, The GP contacted the Locum On Call Medical Registrar at Trafford Hospital, [EN and

asked advice. am advised that further bloods needed to be taken that morning and if no
improvement, to refer to the Acute Medical Unit (AMU) at Trafford General Hospital. Mr Whitby then
had some further blood tests taken at the GP Practice which arrived at the Pathology Laboratory at

Trafford Hospital at 14:27 hours on 06 May 2014.

At approximately 12:00 hours on 07 May 2014, Mr Whitby’s GP reviewed his blood results and noted
his eGFR was 11 and Creatinine 448 which can indicate Stage 5 CKD. Mr Whitby’s GP contacted the
Locum Medical On Call Registrar at Trafford Hospital, [IEE who accepted Mr Whitby for admission
to the Acute Medical Unit (AMU). i—Jcompleted a GP referral proforma and recorded clinical
details of Acute Kidney Injury (AKI) or Chronic Kidney Disease (CKD) with drop in eGFR on the GP
referral form. The GP Practice contacted North West Ambulance Service (NWAS) at 12:29 hours to

arrange for them to collect Mr Whitby and bring him to the AMU.

The results of the blood tests on 06 May should have resulted in urgent discussion with the Mr
Whitby's GP or Mr Whitby himself. There was no escalation of these results by the Biochemistry

Laboratory.

Mr Whitby’s blood results were not escalated by the Chemical Pathology Laboratory on 06 May 2014
as the 500umol/L threshold followed in the Laboratory at that time for Creatinine had not been
breached. Chemical Pathology have now lowered the telephoning limit for Creatinine results from
500umol/L to 400umol/L and these results are telephoned through on the same day.

Consultant Chemical Pathologist, a -: Chief Biomedical Scientist in
Chemical Pathology, have confirmed that a review of the for urgently notifying GPs of
abnormal test results has been undertaken. On 09 March 2015, the Biochemistry Department went

live with an Acute Kidney Injury (AKI) alert system. In future all Stage 3 alerts will be telephoned as
soon as possible on the same day. Stage 1 and 2 alerts will be reviewed on a case by case basis.

Despite blood results, Mr Whitby was not admitted to hospital as an emergency and there was a delay
in recognising the seriousness of these results. Training for junior members of staff on AKI has now

been delivered.

When Mr Whitby was admitted into hospital, there was a failure by the treating medical staff to
recognise his serious medical condition and then a failure to carry out the required medical treatment.

The high level investigation into the care and treatment of Mr Whitby acknowledges that the severity
of his illness was not recognised by the admitting team in the AMU until he became clinically unwell.

Due to this, he was not appropriately managed on admission.

Following the high level investigation, a detailed action plan was agreed and progress was monitored
via the Divisional and Directorate Clinical Effectiveness Committees. All actions are now complete.

The Trust’s AKI guidelines, which support the recognition of severity and the management of AKI in
line with NICE guidance August 2013, have been fully implemented and are clearly displayed on the
Information Board and in the Doctors’ office on the AMU. The guidelines are also now included in the

Handbook provided to Locum Doctors.

Medical and nursing staff on the Acute Medical Unit attended a debriefing session to discuss the care
and treatment of Mr Whitby and the lessons learned. His case was also presented to medical staff at
a Medical Grand Round and was presented more widely at the Divisional Audi ini

Effectiveness (ACE) day on 17 October 2014. The case was presented ii
Consultant, who discussed the missed opportunities and the chain of events. The presentation of Mr
Whitby’s case was followed by a presentation by  aucomrmcercarr Consultant in Nephrology and
Intensive Care Medicine, who explained to staff h TUSL IS tackling AKI. BE «sinc

how AKI was a safety priority for the Trust and also explained the role of the Renal team and of the
AKI Specialist Nurses. 0 discussed the AKI e-alert system which at that time was

under development but has since been successfully implemented Trust wide.

Mr Whitby’s case has also formed an important part of lessons learnt teaching for Junior Doctors
across the Trust and this was followed by teaching of the recognition and management of AKI.

The Inquest also heard evidence that Mr Whitby required transfer to the High Dependency Unit but
this could not take place immediately as two Critical Care Nurses were required and one had been
sent to Manchester Royal Infirmary as was the practice if there were no Patients in the HDU at the
start of their shift.

Since the date of the incident regarding the transfer of Mr Whitby to the High Dependency Unit, two
Critical Care Nurses have been on site at Trafford at all times. The Critical Care Service has recently
reviewed the use of Trafford’s High Dependency Unit and is widening the scope for the type of
patients who can be nursed there in the future. This means that not only will the Critical Care Nurses
be based on the Trafford site — they will be based at all times on the High Dependency Unit.

| hope this letter answers your concerns and gives you and Mr Whitby’s family assurance that lessons
have been learned.

Yours sincerely

Medical Director & Caldicott Guardian
MAHSC Honorary Clinical Professor, University of Manchester

Incorporating:-
Manchester Royal Eye Hospital + Manchester Royal Infirmary - Royal Manchester Children’s Hospital
Saint Mary's Hospital + Trafford Hospitals + University Dental Hospital of Manchester
Community Services

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23 April 2015

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| i Secretary

| wert Telephone

Joanne Kearsley

H M Coroner
Coroner’s Court

1 Mount Tabor Street
Stockport

SK1 3AG

Dear Joanne Kearsley

Mr Bryan Whitby
DOB: 10/07/1926 NHS No:
Telephone No:

Thank you for your letter dated 25" March 2015 with your report regarding investigation into the
death of Mr Bryan Herbert Whitby (deceased).

First of all we would like to clarify the detail regarding Mr Whitby’s renal function blood results.
He was diagnosed with chronic kidney disease stage 3 on 31 January 2013 due to a
deterioration in his kidney function.

At that stage his eGFR had dropped to 34mis per minute. However, this improved over the next
few weeks up to the mid 50’s. On 7" April 2014 it was 60. In general practice it is quite
common to see a reasonable amount of variation in the eGFR test and he had had several
blood tests done in order to monitor this. Mr Whitby made a telephone appointment at the
practice and spoke to n 6 May who noticed that a blood test taken on 2%
May showed a drop in nis e rom 60mls per minute (creatinine 105umol/L) to 40mls per
minute (creatinine 148umol/L) . He had already had his CT scan at that stage.

Our records show Mr Whitby mentioned that his diarrhoea had improved and confirmed that he

hadn't stopped his metformin, also according to contemporaneous notes documented at the
time, Mr Whitby’s records also confirm that ee = to the on-call medical
registrar at Trafford General Hospital in order ain advice due to her concern about the
drop in eGFR. The medical registrar advised NN to prescribe oral magnesium
supplements for a week due to his low magnesium and suggested that he may need

intravenous magnesium and if he did not improve the blood test should be repeated. When he

i130 Broadway, Davyhulme, Manchester M41 7WJ
Telephone 0844 489 0845/0
www.c hut

Email od:

vice regarding his medication, particularly the furosemide, the registrar advised
to leave this at the current dose.

Regarding the matters of concern raised in your letter:

1. As a GP practice we are not usually informed of dates that patients are given for their
investigations by the hospital unless the patient happens to mention this during a consultation
with the GP. We were therefore not aware of the date of his CT scan.

2. The audit trail of the blood tests confirms that the renal function result was sent to the GP
practice automatically on Friday 2" May at 14.03. However this was not seen a

whom it was allocated until Tuesday 6™ May at 9.30am due to this being a bank holiday
weekend.

Mr Whitby’s case was discussed at a Significant Event meeting at the practice and has been
further discussed by the GP’s and managers in recent weeks. Attached is a bullet point list of
the actions that we have and will undertake related to this. In line with normal practice across
the Primary care sector we have not in the past had a policy of checking every result on the day
that it arrives. We have felt that there was a strong argument to maintain a level of continuity of
care with results being seen by the GP who has ordered them but we have now reviewed this

policy in light of Mr Whitby’s case.

The practice relies upon the lab to phone through any abnormal results if urgent attention is
required. These are then passed onto the on call doctor and are dealt with on the day. It was
not felt practical to be able to guarantee to check all results as they come in continuously.
Neither this nor the subsequent kidney function result was phoned through as urgent. We
understood from the hospital critical incident report that the lab at Trafford General was aware
of this and would be reviewing this system. It was also felt that in view of a previous drop in
renal function to a lower level of 34, which had subsequently recovered, most of the GP’s felt
they would have arranged to repeat the blood test in the first instance. Clinical
biochemist at Trafford General Hospital has confirmed that the laboratory protocol at this time
was to telephone practices if a creatinine result is above 500umol/L. The eGFR is a calculated
number derived from the creatinine, an indicator of kidney function.

It was also clarified that as a practice we are not able to see results put on to the hospital
system automatically unless we search for them on a named patient basis. Wi
automatically know about abnormal results in the hospital therefore. In fact

who noted the abnormal results did ring the medical registrar to: obtain further advice. AS a
result of the significant event meeting it was agreed that all GP’s would read the NICE Guidance
on acute kidney injury to improve our management and awareness of this condition in the
future. The need to consider stopping medication potentially toxic to the kidney in high risk
patients was highlighted, as was the need to check blood results on a daily basis to avoid

missing abnormal results.

The GP’s are aware of the need to consider a potential diagnosis of acute kidney injury in high
risk patients and to discuss with the renal team if they have any concerns regarding potential
acute kidney injury.

130 Broadway, Davyhulme, Manchester M41 7Wd
Telephone 0844 489 0845/0161 7- 9 Fax 0161 747 1997
www.davyhulmemedicalcentre.co.uk
Email davyhuimeme 3

3. A repeat blood test result for kidney function requested by | Bae at the practice

on 7 May_2014 and was assigned to cri seven o'clock in the morning. This was
viewed by at one o'clock in the afternoon and he discussed this with the medical

registrar at Trafford General Hospital. In view of a further drop in eGFR to 11mls per minute, he
arranged for an ambulance to take Mr Whitby to Trafford General Hospital.

4. The patient was admitted as a matter of urgency when a 0 viewed the results
clearly recognised their seriousness.

Since this case occurred, in response to an NHS England Patient Safety Alert to tackle acute
kidney injury an electronic alert system has been introduced nationally in adult patients which
was introduced locally on 9 March 2015. This will help to highlight future sudden reductions in

kidney function.

Yours sincerel