Dorothy Cooper

Nicola Jane Mundy
Senior Coroner for South Yorkshire (East District)

ess

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO: Dr Linda Pollard CBE, JP, DL
Chair, Leeds Teaching Hospitals NHS Trust Beckett Street Leeds LS9 7TF
1 CORONER

|! am Nicola Jane Mundy, Senior Coroner for South Yorkshire (East District)

2 CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7

http://www. legislation.gov.uk/uksi/2013/1 629/part/7/made

3 INVESTIGATION and INQUEST

On 13/01/2015 | commenced an investigation into the death of Dorothy Cooper, 75. The
investigation concluded at the end of the inquest on 21 October 2015. The conclusion of the
inquest was Narrative conclusion - Dorothy Cooper underwent elective surgery on 29"
September 2014. Complications from this surgery led to ischaemia of the liver with areas of
infarction which had resolved by the time of her death. The operative procedures, complications
there from and associated poor nutritional status, rendered Mrs Cooper more susceptible to
developing infection which led to overwhelming sepsis, from which she died on 6 January 2015.
The cause of death was: 1a. Sepsis; 2. Elective laparoscopic cholecystectomy and
fundoplication; splenic injury; ischaemic and infarcted liver; poor nutritional status.

4 CIRCUMSTANCES OF THE DEATH

On the 29" September 2014 Mrs Cooper underwent elective laparoscopic cholecystectomy and
fundoplication. Splenic injury occurred at the time of surgery which required laparoscopic repair
two days post operatively. Ischaemia to the liver led to infarction and areas of infection which
resolved by the time of Mrs Cooper's death. However, post operatively she remained in a much
weakened condition, she struggled to eat and had increasingly poor nutritional intake and also
underwent investigations for carcinoma of the liver with ultimately the conclusion being abnormal
changes seen on radiology were likely to be linked to an infective process. On the 4" January
2015 due to Mrs Cooper's extremely poorly state, she was readmitted to the Doncaster Royal
Infirmary where she underwent an acute deterioration on the 6" September and she died in
hospital on that date.

5 CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.

Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DNI 3HS
Tel 01302 320844 | Fax 01302 364833

The MATTERS OF CONCERN are as follows:

During the course of the evidence it became clear that when Pinderfields Hospital (the Mid
Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the
possibility of a liver carcinoma, there was a failure to provide key Information to the receiving
team. The information omitted related to blood tests, full radiological evidence and key stages in
Mrs Cooper's recent medical history. It was clear that had that information been provided, the
clinical picture would have pointed more towards an infective process having been responsible
for Mrs Cooper's condition rather than a cholangiocarcinoma and thus alternative management
was indicated. The receiving team at Leeds identified in their first multi-disciplinary team
meeting that there was insufficient information provided in team of clear clinical parameters but
failed to proactively pursue this.

My concern that if there is not effective training for junior doctors completing the referral form and
systems for ensuring that key information is identified and transferred to the receiving team, and
also that the receiving team have systems in place for ensuring any gaps in the knowledge are
filled, then patients will continue to be at risk in the future where management and treatment
plans are devised on the basis of an incomplete clinical picture.

Matters of concern in summary are :

1. The absence of clear procedures for those in MDT meetings to proactively follow up
inadequately completed referral forms.
2. Lack of procedures to proactively obtain information to complete gaps in clinical history

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you, Dr Linda
Pollard, Chair, have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by
16 December 2015. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

to the Chief Coroner and to the following Interested Persons:
Doncaster Royal Infirmary NHS Foundation Trust and Mid
orkshire Hospital NHS Trust.

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both ina complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.

Signature
Senior Coron

or South Yorkshire (East District)
|

Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS
Tel 01302 320844 | Fax 01302 364833

The Mid Yorkshire Hospitals ["/7 3

NHS Trust

Your ref: NJM/de/tji/47264-2015
Our ref: SE/JHa
Date: 15 December 2015

Mr Jules Preston MBE

To be sent by email to; Chief Executive
Ms Mundy Trust Headquarters and Medical Education Centre
HM Senior Coroner for South aati se
Yorkshire (E istrict akefie!
Crown a a ) West Yorkshire
WF1 4DG

College Road
DN1 3HS
Dear Ms Mundy

RE: Dorothy Cooper, deceased
DOB: 24/2/39 DOD: 6/1/15

| am writing in response to the Regulation 28 Report To Prevent Future Deaths, which
you issued following conclusion of the inquest in regard to the above patient’s death.

Senior clinical colleagues at this Trust have investigated the circumstances around
this patients care, and | enclose a copy of a short report from the Trust’s Lead Cancer
Clinician (who is also a consultant radiologist here at Mid Yorkshire).

The process of inter-provider transfer of care for patients on cancer pathways in West
Yorkshire is being revised, collaboratively at present. Both The Mid Yorkshire
Hospitals NHS Trust and The Leeds Teaching Hospitals NHS Trust are centrally
involved in that improvement work. The main action to improve handover of cases like
Mrs Cooper’s will be to embed the revised processes detailed in the Standard
Operating Procedure being drafted subsequent to that review. We expect this will be
embedded by the end of February 2016.

With respect to the enclosed report, and this correspondence, | would encourage
release or publication of these by the Chief Coroner for reassurance of the users of
our services.

Yours sincerely

( -

Jules Preston MBE
Chairman

Chairman — Jules Preston MBE Chief Executive — Stephen Eames Seivie Ye) for BYXC elle: NC ay

Short Report for MYH Trust Chairman

Subsequent to Regulation 28 Report to Prevent Future Deaths

RE: Dorothy Cooper, deceased DOB 24/2/39 DOD, 6/1/15

BACKGROUND

The patient detailed above died on 6/1/15 following prolonged illness subsequent to
cholecystectomy and fundoplication performed at Doncaster on 29/9/14. She was cared for by our
surgical team, during a prolonged stay in the post-operative period at Mid Yorkshire Hospitals NHS
Trust, during which a series of investigations were undertaken. After the patient’s death the
Coroner, who presided over the inquest, issued a Regulation 28 Report to Prevent Future Deaths.
The MY Trust Chairman has requested that circumstances around her care be investigated locally,
and this report is written as a record of that internal investigation focussed on the Coroner’s
concerns, namely:

1. Inadequate training of junior doctors who complete referral forms

2. A lack of understanding as to what key information is required in referrals of this nature

3. Procedures for ensuring that all recent radiological evidence in matters of this nature is
identified and electronically transmitted to the receiving team

METHODOLOGY

A. The patient’s Mid Yorkshire imaging history was reviewed, alongside imported images from
both Doncaster (2xCT studies) and Leeds (PET-CT study)

B. A number of clinical documents and correspondence, including correspondence between
clinicians here at Mid Yorkshire, along with the Leeds Hepatobiliary MDT annotations were
reviewed

C. The Leeds hepatobiliary MDT pro forma, completed by junior doctor, a member of Mr
Basheer’s team, was reviewed

D. Statements of involved clinicians provided for the coroner were reviewed

FINDINGS

1. Through my regular clinical practice, and close working relationship with several of the
MDT’s at Mid Yorkshire Hospitals, | am aware that the referral processes between local and
specialist MDT’s at Leeds, are well embedded and this routinely includes transfer of imaging
and pathology data. | have confirmed that the pertinent Mid Yorkshire radiological evidence
(including reports) was transferred prior to the initial Leeds HPB MDT evaluation of this
patient.

2. The MDT referral pro forma, completed by the junior doctor in this case, is only a small part

of the referral process. MDT coordinators ensure that the supporting information such as
imaging, which is required for central specialist review, is available in a timely manner. The

statement of Dr Guthrie, in particular, confirmed that was the case for this patient on this
occasion.

3. Both the Leeds Teaching Hospitals, and Mid Yorkshire Hospitals operate an electronic Order
Communications system (“Anglia ICE”), and clinicians can have access to results stored in
those systems. Both Trusts are part of the “ICE Open Net” collaboration, which enables
review of investigation findings including radiology and blood tests in partner institutions. |
cannot confirm whether this patient’s results were accessed using ICE Open Net.

4. With regards to the specific MDT pro forma completed on 11/11/14, | can confirm that the
form is completed in part by a junior doctor, but also finalised by Mr Basheer (handwritten
entry).

5. MDT annotations (following Leeds HPB MDT review on 14/11/14, and 5/12/14) were
completed in the Cancer Information System at Leeds, and distributed on each occasion,
following MDT discussion to the patient’s GP, Mr Basheer, and Mr Hidalgo (nominated
responsible Leeds HPB surgeon).

6. This was a complex case, with a number of GI radiology and clinical specialists from Mid
Yorkshire Hospitals and Leeds Teaching Hospitals, evaluating both the imaging and clinical
picture to determine whether or not the patient had cholangiocarcinoma. This included

a. 2(CT studies performed at Doncaster (1/10/14 and 8/10/14)
b. 2(CT studies(17/10/14 and 18/11/14) at Mid Yorkshire
c. 2MRI studies (28/10/14 and 9/11/14) at Mid Yorkshire
d. PET-CT at Leeds (4/12/15)
All of these were acquired in the post-operative period whilst the patient remained ill.

CONCLUSIONS

1. The junior doctors completing the MDT referral pro forma were well supported by a senior
supervising colleague, in this case by Mr Basheer. Education and training can always be
improved, and once the Inter-Provider Transfer Standard Operating Procedures have been
revised and published, the Mid Yorkshire Hospitals NHS Trust will embed the processes
therein, and will ensure that junior medical staff completing MDT pro forma’s remain well
supported (completion by the end of February 2016)

2. The electronic transfer of imaging and other clinical data to support specialist opinions is
well embedded, and appears to have functioned adequately in this case. Further promotion
of the systems and processes by which this can be achieved will be distributed through our
local Mid Yorkshire MDT’s. (completion by end of January 2016)

3. The author would also like to make readers aware that a Regional Imaging Collaborative has
just begun work to improve system interoperability and image transfer between acute
provider organisations across Yorkshire. Both Leeds Teaching Hospitals and Mid Yorkshire
Hospitals NHS Trusts are actively participating in that collaborative. (Project completion not
expected until early 2017)

Prepared December 2015 by r N Spencer, (GMC#3182839)

Consultant Radiologist and Lead Cancer Clinician, Mid Yorkshire Hospitals NHS Trust

The Leeds Teaching Hospitals NHS)

NHS Trust

Date: 14'" December 2015

Our Ref: YO/A-MWICI2015/4/DC ———
Your Ref: NJM/de/tji/47264-2015 RECEIVED
17 DEC 2015

Chief Medical Officer

Trust Headquarters

St James’s University Hospital
Beckett Street

Ms N J Mundy
Senior Coroner
Coroner's Court and Office

Crown Court Leeds
College Road LS97TF
Doncaster Direct Line: (0113) 20 64688
DN1 3HS Fax: (0113) 20 67007
Email:
PA:

www.leedsth.nhs.uk
Dear Ms Mundy
INQUEST TOUCHING THE DEATH OF DOROTHY COOPER (Deceased)

| refer to your correspondence of 21st October 2015, received on 26th October, regarding the

inquest touching the death of Dorothy Cooper and the Regulation 28 Report to Prevent Future
Deaths in respect of this case. Your letter, addressed to Linda Pollard, has been forwarded on
for me as Chief Medical Officer for the Trust to respond to.

| can confirm that the contents of your Regulation 28 Report have been shared with the
relevant staff to enable us to provide you with a comprehensive response.

In your report you highlight that your matters of concern are:
(1) The absence of clear procedures for those in MDT meetings to proactively follow-up
inadequately completed referral forms;
(2) Lack of procedures to proactively obtain information to complete gaps in clinical history

In your summary you have indicated that had all the information been made available to the
MDT in Mrs Cooper’s case, the clinical picture would have pointed more towards an infective
process having been responsible for her condition rather than cholangiocarcinoma and thus
alternative management would have been indicated.

The team has considered the contents of your correspondence very carefully and the
responses to the matters of concern you have raised in the report are detailed below.

The clinical team have advised me that Ms Cooper was a 75 year old lady who suffered
complications following surgery at Doncaster in September 2014 and she had a prolonged
hospital stay (29/09/14-14/10/14).

She was subsequently admitted to Pinderfields Hospital on 16/10/14 where she was noted to
be very unwell and frail and she was treated appropriately for sepsis. Radiology suggested
the possibility of a bile duct cancer/liver cancer and this was sent to our liver cancer MDT
meeting for review. The referring radiologist requested previous radiology from Doncaster for
comparison to discuss with the local clinicians.

Chair Dr Linda Pollard CBE DL Chief Executive Julian Hartley

The Leeds Teaching Hospitals NHS Trust incorporating: Chapel Allerton Hospital, Leeds Cancer Centre, Leeds Children’s Hospital,
Leeds Dental Institute, Leeds General Infirmary, Seacroft Hospital, St James's University Hospital, Wharfedale Hospital.

The clinical details given to the MDT were vague and the radiology assessment was that there
was a possible tumour but not definite and it was felt that a clinic review and further
investigation was appropriate.

Clinic reviews failed for a variety of reasons, including the wrong address being provided to
the ambulance crew to bring her to clinic from Pinderfields and subsequently because
the patient was too frail. However in between she did attend for further scans.

Further scan review and MDT discussion clarified the overall picture was one of liver
abscesses which by this time had been treated appropriately. The patient was still too frail to
come to clinic but was improving at home so the clinical team at Leeds felt it was appropriate
to suggest a clinic review and further imaging after 3 months and this was arranged after a
clinic review with relatives on 15/12/14.

Sadly, Mrs Cooper suffered a relapse of sepsis (which can occur) and was admitted to
Doncaster on 06/01/15, she presented in a moribund state and died that day.

The MDT has noted that you have raised concerns that they reviewed Mrs Cooper's case at
their MDT meeting without adequate clinical details. They wish to highlight the fact that they
did make attempts to obtain the details by way of correspondence with Mid-Yorkshire NHS
Trust (Pinderfields General Hospital). The team is clear however that the lack of details did
not influence the final diagnosis, treatment or outcome.

The Specialist Hepatobiliary Team is a multi-disciplinary group, which provides a service
covering a population of nearly 5 million both within and outside the Yorkshire Cancer
Network. The aim of the specialist MDT is to ensure a co-ordinated and multi-professional
approach to diagnosis, treatment planning and care provision for patients diagnosed with a
suspected or definite cancer, ensuring timely communication with the appropriate agencies.

The role and remit of the Specialist MDT along with the referral form was first published by the
Yorkshire Cancer Network in April 2012 (Perihilar Cholangiocarcinoma Cancer Network
Pathway). This was updated in line with the re-designed pathway between the West Yorkshire
Diagnostic MDT and the Leeds Specialist Hepatobiliary (HB) MDT in October 2014. Mid-
Yorkshire NHS Trust is part of the Yorkshire Cancer Network and, along with all the other
organisations in the network, are aware they should work to this pathway.

The MDT takes place every Friday morning and details of patients for discussion at the
meeting must be submitted by 3pm on the previous Wednesday by the referring clinicians,
using the agreed MDT pro-forma.

In Mrs Cooper’s case the form was not submitted until 13th November for discussion on 14th
November.

Recently the MDT time allocation has been expanded from 8-11am to 8-12.30pm. On average
55-60 cases are reviewed. The demand on the service is huge and increasing. The staff in
the MDT do their reasonable best to obtain the information they need. The MDT is supported
by an MDT Co-ordinator/Data Manager who collates the cases for review and records the
outcomes of the decisions. There is an increasing tendency to determine a management plan
from a provisional or ‘working’ diagnosis made on the basis of radiological and blood tests but
this must be regarded as provisional and ultimately a tissue diagnosis from a biopsy or
complete resection of the abnormality is required to confirm the impression, or alternatively the
patient is monitored to assess the response to empirical treatment, for example with antibiotics

Chair Dr Linda Pollard CBE DL Chief Executive Julian Hartley

The Leeds Teaching Hospitals NHS Trust incorporating: Chapel Allerton Hospital, Leeds Cancer Centre, Leeds Children’s Hospital,
Leeds Dental Institute, Leeds General Infirmary, Seacroft Hospital, St James's University Hospital, Wharfedale Hospital.

in the case of infection. At the conclusion of the first MDT meeting where Mrs Cooper's case
was discussed, the provisional diagnosis from the referring hospital was not changed but the
plan was made to assess the fitness of the patient in clinic, allowing more clinical detail to be
obtained and an assessment of the fitness of the patient.

The MDT has acknowledged the importance of having sufficient clinical information to be able
to come to an informed decision. However, they have concluded that they cannot agree to
reject any MDT referrals that are not 100% complete because this would add inherent delay
into the system and potentially delay urgent cancer treatment.

To reiterate the importance of submitting relevant clinical information, the Hepatobiliary MDT
Co-ordinator has re-circulated the pathway document that was updated in October 2014 and
highlighted the need for completion of the referral form as fully and accurately as possible.

In addition, the clinical team has altered the MDT reply forms to state in bold on each
response: "The Leeds MDT is pleased to offer advice but responsibility for patient care
remains with the referring team until the patient has been seen in Leeds". Mrs Cooper
was never seen in Leeds in the clinic.

Thank you for bringing these matters to my attention.

Yours sincerely

Ze \ ea

Chief Medical Officer
Leeds Teaching Hospitals NHS Trust

Chair Dr Linda Pollard CBE DL Chief Executive Julian Hartley

The Leeds Teaching Hospitals NHS Trust incorporating: Chapel Allerton Hospital, Leeds Cancer Centre, Leeds Children’s Hospital,
Leeds Dental Institute, Leeds General Infirmary, Seacroft Hospital, St James's University Hospital, Wharfedale Hospital.