Antony Briggs

Stockport NHS)

NHS Foundation Trust

Our ref. AB/CM/PR-letter to HM Coroner-A E Briggs

Your ref. JSP/ER/01250-2015 Oak House
Stepping Hill Hospital

; : Poplar Grove
Coroner's Court R E C E IVE ) "Stockport
Mount Tabor SK2 7JE
Mottram Street 30 MAR 2016
Stockport Telephone: 0161 483 1010

SK13PA 00 ee ee PF Fax: 0161 487 3341
Direct line: 0161 419 5444
E-mail: ann.bames@stockport.nhs.uk

237 March 2016

Dear Mr Pollard,
Re: Antony Edmund BRIGGS (Deceased)

Thank you for your letter, of 28 January 2016, concerning the inquest of the above named patient. As always,
| am grateful to you for highlighting your concerns on the Regulation 28 ‘Report to prevent future deaths’ and
for providing me with an opportunity to respond.

Your concerns are as follows:

1) The system that operates at Buxton is different from that at Stepping Hill and therefore doctors
cannot look at the test results on screen at Stepping Hill and 2) The Urologists see patients at
Stockport, Tameside, Macclesfield and Buxton. At all of these locations, the data can be input so as to
be viewable at Stepping Hill, save and except for Buxton.

This is correct for Radiologica! tests and is historical in that the two systems were developed entirely
independently of each other by different NHS Trusts. Radiology at Buxton is managed by Chesterfield Royal
Hospital NHS Foundation Trust and images are uploaded to their Picture Archiving and Communication
System (PACS), to which Stockport NHS Foundation Trust does not have access. However, visiting Stepping
Hill consultants can view the images and reports on the Chesterfield PACS system when they visit Buxton.

Paper copies of Radiology reports for images taken at Buxton are sent to the Stepping Hill consultant's
secretary at Buxton and if these are noted as urgent, or if the secretary knows the consultant is not going to
visit Buxton for a few weeks, e.g. because of leave, then the Buxton secretary will send the report to the
consultant's secretary at Stepping Hill.

All other tests carried out at Buxton hospital, such as biopsies, or samples of blood, sputum and urine are sent
to Stepping Hill's laboratory and so the results of these tests are uploaded to the ‘Advantis' system and are
visible to staff at both hospitals.

All letters typed at Buxton are typed onto the same Advantis system and are therefore viewable at both
hospitals.

3) When the Urologists view is not available on screen at Stepping Hill, it should apparently fall to the
local GP’s in Buxton to act on the information, but they either cannot or do not, thus the patient falls
into a lacuna and no action is pursued. This is always of importance but especially so with a very
aggressive malignancy.

Mr Briggs was referred to Urology at Buxton on 14 January 2015 and seen on 23 January; he was referred to
Buxton x-ray for an ultra sound scan (‘non-urgent’) and for a flexible cystoscopy at Stepping Hill. The
ultrasound scan was undertaken at Buxton on the 23 February. The report for the scan was also done on 23
February and typed up and sent to the secretary at Buxton on 23 February. The secretary sent it to Mr Brown
for his review when he next attended Buxton, on 6 March.

Your Health. Our Priority.

Mr Brown saw the report and he dictated a letter stating that there was ‘thickening of the bladder wall and that
this may indicate a malignancy’; however the same appearance could also indicate high pressure chronic.
retention or chronic cystitis. Mr Brown therefore advised the G.P. that the patient was awaiting a flexible
cystoscopy and that he would be in touch as soon as this was done; his assumption being that the ultrasound
report and the cystoscopy would be viewed in context with each other.

Mr Briggs was then seen at Stepping Hill on 10 March 2015 by a Registrar and the flexible cystoscopy was
undertaken; the appearance of the bladder seemed ‘normal’ to the Registrar and he wrote a letter to Mr
Briggs’ G.P advising him of this and that he would ‘send the ultrasound report when available’.

It was later noted, in the letter dictated by Mr Brown on 6 March, by the Buxton secretary that the flexible
cystoscopy had been done on 10 March but not reported on; this letter was not typed into the Advantis system
until 41 March.

The courses of action taken by Mr Brown and the Registrar, in themselves, were perfectly reasonable; Mr
Brown thinking that the cystoscopy would be undertaken with the Registrar having benefit of sight of his letter
and the Registrar, having viewed what he felt to be a normal bladder, informing the G.P. of this and that he
would write to Mr Briggs with the results of the ultrasound scan, once known.

It is worthy of note at this point that Mr Briggs had an extremely rare form of cancer, an infiltrating adeno-
carcinoma. One would normally expect to see, if a bladder tumour were present, papillary areas that were
very obvious. The Registrar, at his level of experience, acted appropriately and he cannot be criticised for not
detecting the adeno-carcinoma; indeed it is very possible that a consultant under the same set of
circumstances may not have detected it either.

The ultrasound scan report was not marked ‘urgent’, as the index of suspicion regarding the appearance of
the bladder was not high enough for the reporter given that, as mentioned previously, the same appearance
could be the result of high pressure chronic retention or chronic cystitis. This, in addition to the ‘time lag’ in
getting Mr. Brown's letter typed into the Advantis system and the fact that the Registrar was not aware of the
report contributed to the delay in the diagnosis of Mr Briggs’ adeno-carcinoma.

Although extremely rare, this case has clearly exposed a weakness in our communications between Buxton
and Stepping Hill.

4) This man had an infiltrating adeno-carcinoma, which is very rare. This fact was not picked up as
soon as it could have been and was not, therefore, acted upon.

| have answered this point earlier in this response.

Action

We will strengthen communications between the secretarial teams at Stepping Hill and Buxton to ensure that
Radiology reports are made available to both sites at the same time. One way of doing this will be to jointly
develop and agreed a robust standard operating procedure to ensure that all reports for Radiology activity
undertaken at Buxton on behalf of Stepping Hill, regardless of whether or not they are marked urgent, are sent
over to the relevant consultant's secretary at Stepping Hill for the necessary review and action.

| hope that this response answers your concerns and provides you with the assurance that the Trust is
committed to improving the quality of care we give to all our patients. Please do not hesitate to contact me if
you have any further questions regarding this matter.

Yours sincerely,

Chief Executive