David Little

Tameside Hospital INHS

NHS Foundation Trust

Quality & Governance Unit
Tameside General Hospital
Fountain Street
Ashton-under-Lyne
Lancashire

Miss Joanne Kearsley woeee ee HCE
Acting Senior Coroner for Manchester Sout”
The Coroners Court

1 Mount Tabor Street

Stockport

SK1 3AG

22™ August 2016

Your Ref:

Dear Miss Kearsley,

Re: Regulation 28: Report to Prevent Future Deaths following inquest into the
death of David Little (Deceased)

| write further to Mr Pollard’s letter dated 29 June 2016 enclosing a Regulation 28 Report
issued at the conclusion of the inquest touching upon the death of David Little, which took place
on 28 June 2016. | am, of course, very sorry that Mr Pollard had cause to issue this report.

| hope to be able to address these concerns, as set out in Section 5 of the report, to your
satisfaction, in this letter. | have addressed the areas of concer, adopting the same number in
Section 5 of the report as follows:

1. There was strong evidence of a failure by the hospital staff to keep clear records of
when an inpatient was to be taken to “radiology”, for what purpose, whether the patient
had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in
the belief that he was another patient, and it was only on arrival at radiology that this
was realised when they decided to proceed with his scan which had been planned for
the following day.

Further investigation has revealed that the computer records from the Radiology CRIS system
show that the request for Mr Little's CT scan was made at 11:29hrs on 10 June 2015 and the
fequest was actioned at 11:33hrs on the same day. At this time the appointment was
scheduled for 15:30hrs on the same day and Mr Little attended at 15:29hrs. The CRIS system
does not show that he was initially scheduled for the following day. Therefore, in terms of
whether Mr Little was taken ‘by mistake’, this does not appear to be the case as Mr Little was
expected in the department at 15:30hrs on 10 June.

On reviewing the evidence given by the family andl at the inquest, it is clear that
there was certainly some confusion about when his scan was due to be performed and it is
accepted that it was likely poor and confusing communication between - “the Radiology oh
department and the ward/clinicians that was the root cause. a \

casual

Everyone
Matters

When a request is required very urgently for a patient, as was the case with Mr Little, prior to
the request being accepted by Radiology to prioritise the patient, it is mandatory for the clinician
to phone the department to discuss the clinical urgency with the Radiologist of the day. This is
to ensure that the correct clinical priority is assigned and that the patient receives the required
input from the radiologist to ensure the most appropriate investigation is requested for the
presenting condition. It is noted that this process of communication with the ward following the
acceptance of the scan by the Radiologist of the day may have been the source of confusion.
This likely took place before the scan request was placed on the system, at which point, a slot
had been found for Mr Little that day, but this did not appear to have been communicated to the
ward or clinicians.

Following Mr Little’s death, the department has published a ‘Radiology Requesting and
Reporting Policy’ in February 2016 (Document 1 attached). The Policy requires the clinician to
document the discussion in the clinical notes of the request made to Radiology and the
response given. Once the scan is requested, the Radiology department must then ensure that
they document any changes to the planned appointment and communicate them with the
responsible clinician. It is clear that at the time of Mr Little's death, the communication
appeared to be confusing and there are insufficient documented records to confirm what
conversations actually took place at the time.

In addition, there is currently a documented tracking/handover policy in draft (Document 2
attached) which will document any specific requests that are given to the patient via the ward
staff to prepare them for their investigation, e.g. nil by mouth or the requirement for a full
bladder. {t will include a feedback form that the porter will take to the ward when collecting the
patient for a member of the nursing staff to sign to confirm the patient's identification and the
testimaging the patient is scheduled for. On return of the patient to the ward, the sheet will
document what investigation has taken place and any special observations required. This form
will form a part of the radiology record and be filed in the patient’s notes.

It is anticipated that both these processes together will ensure that the responsibilities of both
the requesting clinician and the Radiology department are clear, there is better communication
between Radiology and the ward staff/requesting clinicians, and that the communication is
documented and auditable.

2. The hospital had no clear diagnostic pathway or monitoring plan on admission, the staff
appeared not to be trained to recognise the symptoms of a blocked bowel not the
potential seriousness thereof not to be aware of the dire consequences of failure to
diagnose and treat appropriately.

The Trust has devised a small bowel obstruction surgical pathway (Document 3 attached)
which now describes the pathway and monitoring plan for this patient group. Learning
undertaken following Mr Little’s death has been incorporated into this pathway. It has been
agreed by the surgical, nursing and clinical teams and will be ratified as described in the
document, through the governance forums in General Surgery, Radiology, Urgent Care &
Critical Care before being signed off at Trust level by the end of September.

3. Where there is a differential diagnosis of two or more potential conditions, the staff
simply treated the least serious and assumed that was the correct diagnosis rather than
taking the most serious and working backwards from that standpoint.

The pathway described in point 2, addresses the appropriate consideration that should be
given to various clinical conditions and their clinical priority.

4. The communication between and among staff generally was poor but especially
between the radiology department and the clinicians and nurses. There was little or no

good communication with the family which led to additional distress for them at a time of
great sorrow.

The Trust sincerely apologises to Mr Little’s family. The response to point 1 is anticipated to
significantly improve the communication between the radiology department and the clinicians
and nurses.

The Trust have invited the family to discuss their concerns directly with the Trust and are more
than happy to involve the family with ongoing learning in order to improve on general
communication with family members.

Should you have any further queries arising from the contents of this letter, please do not
hesitate to contact me.

Yours sincerely,

Karen James
Chief Executive

ce. NHS Improvement
cac
Tameside and Glossop CCG