Adrian Smith

gf’ HEART of
NHS| FL ENGLAND

NHS Foundation Trust

Birmingham Heartlands Hospital
Bordesley Green East

Birmingham

B9 5SS

Tel: 0121 424 2320
CR/AF/SCC

1 December 2015

Mrs Louise Hunt

HM Senior Coroner for Birmingham and Solihull
50 Newton Street

Birmingham

Dear Mrs Hunt,

Inquest into the death of Mr Adrian Mark Smith — Report to Prevent Future Deaths

| write in response to the Regulation 28 Report made by you following your investigation and inquest
into the death of Mr Adrian Mark Smith on 14 October 2015 and your letter to Dr Andrew Catto
(Executive Medical Director) dated 16 October 2015.

|.am responding on behalf of Dr Catto and in my capacity as the Trust Deputy Medical Director.

The Heart of England NHS Foundation Trust (the "Trust") has carefully considered the important
matters raised by you at the inquest and | set out the Trust's response below:

4. Clear instruction was given by the Queen Elizabeth Hospital to undertake an MRI scan to
confirm the possible diagnosis. This instruction was not followed by the staff at Good Hope
Hospital. Systems need to be put in place to ensure that specialist advice is followed.

In responding to your Regulation 28 Report, we have sought the views of the senior responsible
clinician for radiology, Dr John Reynolds (Clinical Director).

When reflecting on this case, has discussed with me that it is a rare occurrence thata
specialist requested radiological investigation is declined by a consultant radiologist,

suggests it is a maximum of 1% of specialist requested investigations that are questioned and the
decision to decline a requested investigation is always made by a consultant radiologist in discussion
with members of the clinical team responsible for the patient. It should be acknowledged that the
radiologist involvement is not simply technical (fo do as told) but to provide an opinion and action a

clinical request based upon need.

The initial contact with the external neurosurgical team is normally made by a member of the clinical
team caring for the patient speaking to a neurosurgical registrar and inevitably the experience of the
registrar can be variable {EEN has advised that there have been no reported incidents where a
patient has suffered an adverse outcome following a radiological investigation being declined. This
does not however minimise the seriousness of the concerns raised regarding the potential risk to
patients in our care.

When considering any radiological investigation request | have been informed that the following is
routinely considered: First, whether the requested investigation is likely to identify new clinical
information, and secondly whether the investigation is likely to lead to clinical intervention. These points
are considered alongside the risks for each individual patient, and the demands on the service.

In order that the risk of future events can be reduced the following steps have been taken by the Trust:

4. In the circumstances where a consultant radiologist does not believe that a requested radiological
investigation is likely to identify new clinical information or lead to clinical intervention, before the
request is declined they will now discuss the case with a HEFT peer consultant radiologist to seek a
second opinion and ensure that their assessment Is both reasonable and logical. The consultant in
charge of the patient's care will also be involved in the discussion.

2. In addition to strengthening the decision making process, if after a peer discussion, both consultant
radiologists are of the professional opinion that the investigation should not be undertaken, or an
alternative investigation should be undertaken, how this is communicated to the neurosurgical team will
change. Currently the process would be that the treating clinical team liaise with the neurosurgical team
regarding patient management, and it is the treating clinical team that currently communicate the
decision to decline any requested investigation. The process, in future, will be that if the decision is to
query the requested investigation then the consultant radiologist will speak directly with the senior
neurosurgeon to discuss the case and their clinical decision. This will facilitate open discussion
between senior clinicians to ensure the correct clinical decision is reached for each individual patient.

In order to facilitate this more collaborative working approach has agreed to liaise with the
Clinical Lead for Neurosurgery at Queen Elizabeth Hospital, and the Divisional Director
for | to ensure that the neurosurgical team are aware of and approve our
proposed changes.

To ensure these actions are consistently applied across the radiology directorate [has
agreed to develop a standard operating procedure (SOP) that clearly and concisely articulates the
strengthened process.

Finally, in sad situations such as this, it is important that the family of Mr Smith are made aware of the
steps that we are taking to reduce the risk of future events. | will arrange to meet with the family
directly.

if | can be of any further assistance, please do not hesitate to contact me.

Best wishes.

Yours sincerely,
Dr Cli er

Deputy Medical Director

Encs

cc
Dr Andrew Catto, Executive Medical Director

MEE '¢1 Nurse

| Deputy Director of Governance

Dr David Rosser, Deputy Chief Executive
BEE Director Division D QEHB