Constance Pridmore

From Ben ner MP

Parliamentary Under Secretary of Stat re Quality

Department
of Health itch
POC 1034475 SWI1A 2NS

Tel: 020 7210 4850

Mr Paul O’ Donnell
HM Assistant Coroner
65 Duke Street
Barrow-in-Furness

Cumbria
LA14 IRW

[Cid 2016

Ure MW Slow ——

Thank you for your letter to Secretary of State about the death of Ms Constance Pridmore. I
am responding as the Minister with responsibility for patient safety at the Department of

Health.

I was saddened to read of the circumstances surrounding Mrs Pridmore’s death. Please pass
my condolences to her family and loved ones.

Your report outlined the evidence given by several doctors at Mrs Pridmore’s inquest and
noted the following concerns, some of which are for the Morecambe Bay Foundation Trust to

address:

iii.

the shortage of radiologists within the Morecambe Bay Trust which prevented Mrs
Pridmore’s x-ray from being reviewed by a radiologist sooner is reflective of a
critical shortage of radiologists in the U.K.

there are presently approximately 400 vacant consultant radiologist posts in the
U.K.

the target set in Professor Sir Bruce Keogh’s 2013 report entitled ‘NHS Services,
Seven days a Week’ (Paper NHS12131 5) for urgent x-rays of inpatients to be
completed (including the reporting by a radiologist) within 12 hours is far from
being achieved both locally by Morecambe Bay Trust, but also nationally by all
Health Trusts.

This is due in part to a general increase in the use of scans and x-rays as
diagnostic aids, but mainly due to the acute shortage of radiologist who are
available and trained to interpret the relevant data accurately and in a timely
manner, The Keogh targets whilst intended to become reality by the end of 2017
are becoming a more distant ideal than a realistically approaching target.

v. It is probable that current delays on both a local and national basis in obtaining in
a timely manner, accurate radiologist reports of x-rays and CT scans taken for
diagnostic purposes. creates a foreseeable risk that further deaths may well arise

as a consequence,

vi. Locally, a review of your procedures with regard to the assessment of x-rays is
required and nationally, a review into the implementation of the recommendations
of the Keogh report is likely to be necessary.

Responsibility for staffing rests, as it has always done, with Trust boards. Trusts should focus
on the numbers and skill mix needed to deliver quality care, patient safety and efficiency,

taking into account local factors such as acuity and case mix.

We expect all parts of the NHS to have staffing arrangements that deliver safe care — making
sure they have the right staff, in the right place, at the right time to provide safe and effective

care and to make the best use of their resources in doing so.

Health and Social Care Information Centre (HSCIC) statistics, show that Morecambe Bay
shows a higher percentage increase (25%) in the number of clinical radiologists than in

England (20.9%)
England Clinical Radiology FTE
May 2010 Mar 2015 Mar 2016 Change Mar Change May
2015 to Mar 2010 to Mar
2016 2016
HCHS 5
Doctors 3,253 3,769 3,932 163 (4.3%) | 680 (20.9%)
of which:
Consultant
(including °
Directors of 2,285 2,697 2,814 117 (3%) | 529 (23.2%)
Public Health)

Source: HSCIC NHS Workforce monthly as at 31/3/16

University Hospitals of Morecambe Bay NHS Foundation Trust

May 2010 Mar 2015 Mar 2016 Change Mar Change May
2015 to Mar 2010 to Mar
2016 2016
HCHS ° °
Doctors 13 14 16 2 (14.3%) 3 (25.0%)
of which:
Consultant
(including 6
Directors of 11 12 13 1 (8.3%) 2 (20.4%)
Public Health)

However, we recognise the need to continue to build the radiology workforce.

ay
Department
of Health

Heath Education England’s (HEE) plans the future workforce on a national basis and is
taking forward a programme of action to support the Government’s commitment to the
diagnostics specialisms. Consultants in Clinical Radiology have been prioritised as part of
HEE’s investment planning process. Training posts will further increase by 32 in 2016.

Work is currently in progress in respect of the radiography, radiology, non-medical
endoscopy (NME), pathology, and sonography workforces.

Clinical Radiology has also been one of the five large specialty reviews undertaken by the
planning team this year, the outcomes of which will be reported over the summer to decide
intakes from 2017 onwards. This takes into account the workforce demands of the Urgent
and Emergency Care Review work and will form a key element of planning support to the
wider programme.

NHS England reports that the Urgent and Emergency Care Review arising from Sir Bruce
Keogh’s work is now in its implementation phase. Key to implementation is the
development of urgent and emergency care (UEC) networks. In June 2015, NHS England
published guidance for what were then emerging networks titled Role and Establishment of
Urgent and Emergency Care Networks and in October a total of 23 UEC networks across the
four regions of NHS England were confirmed.

In November, a “route map” was published by the NHS outlining the high-level expectations,
support products, national work programmes and the expectations of UEC networks and their
constituent CCGs. The UEC networks are now mobilised and have responsibility to describe,
develop and agree clinical pathways for urgent and emergency care in their geographies.

Specifically, these networks will describe how and where patients can access the care they
need as conveniently as possible, the access to definitive care of all categories, severity and
complexity of emergency for their defined geography and will oversee the designation of
services and monitor network performance, patient outcomes and service access.

I hope that this informatiog is useful. Thank you for bringing the circumstances of Mrs
Pridmore’s death to oyir atfention.

BEN GUMMER

University Hospitals INAS
of Morecambe Bay
NHS Foundation Trust

Chair and Chief Executive's Office
Westmorland Genera! Hospital
Burton Road

Kendal

LAS 7RG

Tel: 01539 716695

Fax; 01539 795313

Web: www.uhmb.nhs.uk

Paul O'Donnell, HM Assistant Coroner
65 Duke Street,

Barrow-In-Fumess

Cumbria

LA14 1RW

Our Ref: JD/PO
30 June 2016

Dear Mr O'Donnell
Re: Regulation 28 Report To Prevent Future Deaths — Constance Pridmore (deceased

Thank you for your report dated 12 May 2016, requesting a review of the Trust’s procedures with regard to the
assessment of x-rays, on the basis that delays in oblaining radiologists’ reports creates a foreseeable risk of
future deaths.

The Trust's Clinical Director for Core Clinical Services and Consultant Radiologist has reviewed our procedures
and | can advise as follows.

In n

The number and range of imaging investigations performed per day varies but the reporting workload is broadly
predictable and University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB) does not have sufficient
reporting capacity to promplly report all the images that are acquired. As identified in your report, there Is a
shorlage of radiologists and this is reflective of a national problem. The Royal College of Radiologists (RCR)
has produced several snapshot surveys demonstrating the scale of the issue. The most recent RCR survey
(February 2016) showed that in fact, UHMB was in the upper quartile with no studies >1 month.

In addition, radiology services nationally have experienced continual growth over the last eight years and this
trend is expected to continue. In relation to changes in clinical practice, as clinical applications within imaging
technology advance, the Trust will continue to increase demand for the service. There is also an increased
dependence upon radiological investigations by clinicians to support the clinical decision-making process.

In 2013, Professor Sir Bruce Keogh’s report recommended that all inpatient imaging investigations be completed
and reported within 24 hours. However, the shortage of radiologists and Increase in workload means that this

Westmorland General Hospital

Burton Road

Kendal

LAS 7RG CHAIR: PEARSE BUTLER

Tel: 01539 732288 CHIEF EXECUTIVE: JACKIE DANIEL

standard, intended for achievement by 2016/17, Is widely accepted to be an ideal rather than a realistic target.
The Trust continues to work towards this but it is a challenge. The lack of reporting capacity and associated risk
is appropriately recorded on our corporate risk register, which is reviewed at least on a quarterly basis. In
addition to prioritisation, the main actions to address this are around recruitment, skill mix and use of technology.

Background

Approximately 300,000 imaging investigations per annum are performed at UHMB, of which 170,000 are x-rays.
For these to be useful, the images need to be considered and an opinian documented. For those tests which
involve radiation, this is also a statutory duty under the fonising Radiation (Medical Exposure) Regulations. For
many studies the images will be immediately available and will be reviewed by the clinician who has requested
them. It is normal practice in this trust and elsewhere that their opinion is used as the basts for treatment, at
least until such time as the study is ‘reported’. The documentation of an opinion by someone whose main role is
evaluating imaging is known as ‘reporting’ and is usually carried out by a radiologist or a specially trained
‘reporting radiographer’.

Reporilng and Referrer Evaluation

A small number of studies are considered suitable for ‘referrer evaluation’ and the opinion documented will be
that of the referrer, wilh an option to ask for the film to be reviewed and reported by a radiologist. In these cases
there would be no formal report issued by a radiologist. Examples of x-rays that are considered suitable for
referrer evaluation at UHMB include x-rays of the teeth reviewed by a dentist and follow up x-rays of healing
fractures in adults reviewed by an orthopaedic surgeon.

The reason for reporter evaluation is to make best use of reporting capacity and also because the referrer is
sometimes in a better position to judge whether the findings are acceptable, for instance when an x-ray relates to

previous surgery and the surgeon is the best judge of whether any implanted hardware is where they intended it
to be.

Referrer evaluation is standard practice in NHS hospitals, although its scope varies. There are many centres, for
example, which apply this to all in-patient x-rays but the policy at UHMB is considerably less extensive. The
potential for increasing the scope of referrer evaluation to provide greater reporting capacity for other studies has
been considered through the Trust's Governance procedures but our preferred option has been to try to
maximise the reporting capacity available to us. We believe the scope of referrer evaluation within the Trust to

be reasonable and safe and there is a standard operating procedure to quide reporters on the Trust's working
practices relating to image reporting.

Some Trusts do not report images where a patient has died between the acquisition and the reporting of the
image but having sought advice on this from the Medical Protection Society, UHMB continues to do so.

Workin ngements and Prioritisation

Within UHMB the Picture Archiving and Communication (PACS) system Is shared across five sites and as far as
possible the departments prioritise an the basis of urgency rather than geography.

Work is divided into emergency cover, ‘duty radiologist’ sessions and multi-disciplinary team meeting (MDT)
support, with the remaining clinical time as reporting time. This is subdivided into different modalities (plain x-
rays, CT, MRI, etc.) with the split depending on the reporters’ area of expertise and the volume of work.

Information about the number of studies waiting and the date of the oldest studies in each modality are sent to
every reporter twice a week. Within each session the default position is to start with the studies marked clinically
urgent and then chronologically with the oldest study and work towards the present, but reporters are expected
to exercise their clinical judgement as to exactly which studies to report. Not all reporters can report the same
range of studies and no one person can report evary kind of study.

The waiting images are actively managed by a radiographic manager who will also send work to outsourcing
companies as required.

Without additional reporting capacily prioritisation remains important. There are no national guidelines on this
and although consideration has been given to constructing a flow diagram to assist with this, the complexity of
what is ultimately a clinical decision based on a number of factors across a range of modalities does not lend
itself to such simplification.

Urgency of imaging

Some studies are more urgent than others. Sometimes this is apparent from the moment of referral, for instance
@ patient brought into the Emergency Department in extremis. At other times, however, it is not apparent that

there are critically important findings that might immediately change the patient's treatment until afler the image
has been reported.

When it appears that a study is urgent then it is prioritised accordingly using the professional judgement of those
in the x-ray department. However, clinical risk occurs if prioritising urgent cases causes delays in reporting of
routine requests, as significant findings are also discovered in this group of patients. Balancing this is a further
challenge.

Key P. ance |

Key Performance Indicators are measured via data extraction from the Computerised Radiology Information
System (CRIS) and a performance dashboard is populated.

Reporting backlog is monitored daily
¢ Waiting fist tracking and activity measures are reported weekly
© Regular job pian review and productivity monitoring is in place for all radiologists
° Capacity and demand work is regularly undertaken

Workforce

The Dalton Review reported that the UK has around 46 trained radiologists per million population. This figure
has remained stalic for the last five years and represents half the total in other EU countries. The paper
considers different ways of working in terms of outsourcing, skill mix and the use of technology to overcome the
challenge and UHMB has already implemented some of these ideas. In the UK, no appointment was made to
41% of unfilled consultant posts advertised and the North West showed a higher vacancy rate than other
regions. This reflects the experience in UHMB where there are currently 5 vacancies, based on workload
calculations from 2011, since which time CT and MR have both doubled in volume and Increased in complexity.

Clearly recruitment is central to developing further capacity and the Trust has made progress and appointed
three radiologists in the past 12 months with ongoing recruitment efforts, including international recruitment.

Further actions relating to recruitment and skill mix include:

e Rolling programme of in-house training for CT/MR radiographers
® Radiographer training plans have been identified to future proof services, with funding opportunities for
training identified

¢ Additional programmed activities and payment are on offer to substantive consultants to report additional
work beyond their normal employed hours

Westmorland General Hospital

Burton Road

Kendal

LAG 7RG CHAIR: PEARSE BUTLER

Tel: 01539 732288 CHIEF EXECUTIVE: JACKIE DANIEL

° Support for undergraduate radiographer training from the University of Cumbria and elective placements
from other universities to attract new recruits

° Maximisation of advanced practitioner skills

e 8 honorary contracts with external radiologists who provide ad hoc support

© Trust associate specialist posts available

* Rotas for 7 day and extended day services agreed for radiographers in CT/MR and sonographers in
Ullrasound.

¢ Locum radiologists employed when suitable and available

¢ Advice and guidance introduced to enable GPs to have email conversations for advice and access to
more complex diagnostics — to avoid unnecessary imaging requests and streamline the patient pathway

e Workforce planning to review skill mix and age profile of staff

tions relatin lechnology include:

e Home reporting to be explored with the advent of new PACS from September 2016, which should
improve recruitment and retention opportunities

« Voice recognition technology has been rolled out across all radiology staff, streamlining the process and
speeding up report turnaround times

er actions and development: ide:

¢ Continued involvement in the ‘Better Care Together’ strategy with partner health care providers to

develop clear patient pathways, optimising use of imaging services, reducing unnecessary requests and
improving patient outcomes

¢ Optimisation project to ensure relevant diagnostic tests are performed at the right time within specific
Patient pathways and unnecessary imaging requests are avoided

| hope that you find this information helpful but if you should require any further information, please do not
hesitate to contact me.

Yours sincerely,

Jackie Daniel
Chief Executive

cc The Rt Hon Jeremy Hunt MP, Secretary of State for Health, Department of Health