Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0113, written 10 Apr 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Apr 2017 |
|---|---|
| Reference | 2017-0113 |
| Deceased | John Higgs |
| Coroner | Sarah Slater |
| Coroner area | South Yorkshire (West) |
| Category | Other related deaths |
| Organisation named | Barnsley Hospital NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Secretary of State for Health 1 CORONER Sarah Louise Slater, Assistant Coroner for South Yorkshire (West) 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigatory) Regulations 2013. (1) Where – a. A senior coroner has been conducting an investigation under this Part into a person’s death and b. Anything the revealed by investigation gives that circumstances creating a risk or other deaths will occur, or will continue to exist, in the future, and In the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have the power to take such action. to concern rise c. (2) A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it. (3) A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner 3 INVESTIGATION and INQUEST On 22nd December 2016 I commenced an investigation into the death of Mr John Higgs. The investigation concluded at the end of the inquest on 7th April 2017. The conclusion of the inquest was that Mr Higgs died from 1(a) Ruptured Abdominal Aortic Aneurysm 2. Stroke, Frailty of old age A narrative conclusion was recorded as follows: Mr Higgs died in Barnsley General Hospital on the 18th November 2015 as a result of a ruptured abdominal aortic aneurysm. 1 In March 2011, Mr Higgs attended Barnsley General Hospital and underwent a CT scan which identified the presence of a 6cm abdominal aortic aneurysm. This finding was not communicated to Mr Higgs despite him attending at the hospital on a number of occasions following the scan. In addition, the general practitioner was not informed therefore Mr Higgs was not referred to specialist vascular surgeons and he did not have the opportunity to consider any further treatment options prior to his sudden collapse in 2015. 4 CIRCUMSTANCES OF THE DEATH Mr Higgs attended Barnsley General Hospital on the 18th November 2015 following a fall and vacant episode. It was initially though that Mr Higgs had suffered a further stroke but an ultrasound scan revealed a 6.6cm abdominal aortic aneurysm which was leaking. He Higgs died later that same day. After Mr Higgs death, his wife received the death certificate and sent a letter to the hospital asking why she had not been informed that he husband had an aneurysm. This was investigated by the Trust and it was found that Mr Higgs had undergone a CT scan in March 2011 and the scan had identified the presence of a 6cm abdominal aortic aneurysm but the results had been overlooked at the time and therefore not communicated to Mr Higgs, other clinicians or his general practitioner. The evidence at the inquest was that presence of the abdominal aortic aneurysm was an unexpected finding on the CT scan. The report had been seen by the Consultant Surgeon in charge of the care, but he did not act upon these results because Mr Higgs was attending clinic 5 days later and therefore the Consultant would discuss them with the patient. At this time, the trust relied on paper records. Mr Higgs attended clinic and was seen by a junior doctor who either did not review the CT report or it was unavailable because it was still with the consultant awaiting filing on the patient records. There was no evidence in court of a safe system of communication at the time (2011). Mr Higgs attended at the hospital on a number of occasions after the scan results were available in 2011 and was seen by several different doctors but the CT scan results from 2011 were not looked at. In addition, the general practitioner was not informed therefore Mr Higgs was not referred to specialist vascular surgeons and he did not have the opportunity to consider any further treatment options prior to his sudden collapse in 2015. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving raise 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. The MATTER OF CONCERN for the Secretary of State to consider is as follows: The inquest heard that the Trust now relies on an electronic system rather than the paper system as it did in 2011. However, any unexpected significant/serious radiological finding are still included in a report that is only sent to the Consultant in charge of the care and it is a matter for that doctor to notice that part of the report and to input this information on the system as a message. In essence, the procedures appear to be the same, it the mode of recording the information that had changed from paper to computer. No other measures have been put in place and the system is still reliant on 2 one doctor noticing and recording the information. In addition, the Court heard there was no facility to place a “red flag” on the system to increase the likelihood of other clinicians being made aware of these unexpected and significant findings. The Trust has a radiology protocol for “unexpected cancer pathology” where the results are sent to the treating Consultant but also sent to the MDT Cancer Co-ordinator for action but no such protocol exists for non- cancerous but significant and potentially life threatening findings. The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to “unexpected (non- cancerous) radiological findings because HMAC is concerned that this situation could occur again. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th June 2017. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mr Higgs Chief Executive, Barnsley District General Hospital I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a 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. 9 10th April 2017 Louise Slater Assistant Coroner South Yorkshire (West) 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
$e Barnsley Hospital Barnsley Hospital NHS)
oh e Quality in Care NHS Foundation Trust
Direct contact: P| Gawber Road
Tel: 01226 431800 Barnsley
Fax: 014226 284179 $75 2EP
e-mail:
Tel: 01226 730000
Fax: 01226 202859
Minicom: 01226 321014
Mrs S$ L Slater e 9 JON QO |
Assistant Coroner “HLM wauaeisees o veri!
South Yorkshire (West) _ ~
Medico Legal Centre
Watery Street
Sheffield
$3 7ES
Our ref: KST/ RJ
23" June 2017
Dear Mrs Slater
Re: Mr John Higgs dob 23/5/29 (Deceased)
| am writing in response to your letter dated 10 April 2017 sent to me under the provisions of
Regulation 28 of the Coroner’s Investigation Regulations 2013, relating to the inquest of Mr John
Higgs held on 7 April 2017.
| am grateful for your letter as this has highlighted an area within the Trust in which patient care and
safety can be improved.
On 20 April 2017 a meeting took place betwee Mi Interim Medical Director ||
Deputy Medical Director, Head of Radiology, fo
and General Manager responsible for Radiology and Fs Interim Trust Solicitor to
review your letter and discuss the actions and response to your concerns in Part 5 of the Regulation
28.
Taking each paragraph in turn of HM Coroner’s Concerns at Part 5:
Paragraphs 1 and.2
At the meeting on 20 April 2017 it was established that there is in fact already in existence guidance
which covers unexpected or urgent findings and communication of critical or urgent unexpected
significant radiological findings. This is called Guidance on Communication of Critical or Urgent or
www-barnsleyhospital.nhs.uk re) @barnshospital rf] www.facebook.com/barnsleyhospital
Unexpected Significant Radiological Findings (“Guidance”). It is unfortunate that this did not come
to light at the recent inquest. | apologise to you and to Mr Higgs’s family.
We will ensure that the Guidance is re-issued to the relevant clinical staff who have joined our
organisation after 2016. We have included the Guidance as the basis of the Patient Safety Bulletin.
In addition, the policy and Regulation 28 response will be reviewed and disseminated at the
quarterly Quality and Governance Committee which is attended by senior medical , nursing and
managerial staff.
By way of background the Guidance came in to existence on 16 January 2012 (EXH 1 and 1A) and
was completely re-written and comprehensively updated in October 2015 b In
line with Trust policy review requirements, this document has been re-reviewed and minor changes
made in July 2016 (EXH 3).The versions of the Guidance from January 2012 to date are enclosed
and for your information and consideration.
The Guidance essentially sets out in detail how to report incidental radiological findings and in what
manner this should be achieved, this local Guidance accords with the Royal College of Radiologists
("RCR’) standards for fail safe alert systems documentation which was published in May 2016. HM
Coroner's attention is kindly drawn to page 10, Paragraph 4(B) of the guidance.
HE ontirms the combination of the new Guidance, advice sought and the electronic reporting
systems (ICE) now in place would significantly reduce the risk of a similar incident occurring in the
future. The radiologist would be able to flag up a serious incidental finding to the treating clinician
for their prompt action.
Paragraph 3
Barnsley Hospital NHS Foundation Trust has reviewed its processes for interpretation and
communication of serious but incidental findings, and has considered its processes which are set
out above.
It is acknowledged throughout the NHS nationally that there is a problem. We have made contact
with other local NHS Trusts and been advised that the prompt review and actioning of the result by
clinician’s is however an area which may require improvement. The above Guidance has, in line
with Royal College of Radiologist standards, improved significantly the reporting of incidental
findings. We firmly believe that the measures that we have put in place will significantly reduce the
likelihood of future deaths.
As a Trust we realise human error is a factor in many of our processes, we manage those by
introducing policies and systems to minimise incidents of this nature occurring. It is clear following
our enquires that the potential for human error remains an issue for all NHS Trusts.
Results acknowledgement and/or action is not a local problem unique to Barnsley (or is it unique to
the NHS). It is a global issue for which various different methods have been used to try and resolve
the problem. Such methods have spanned from using third party applications to administer the two
way acknowledgement process (Christchurch Hospital, New Zealand) through to changes in
Page 2 of 3
legislation making it a legal duty of the requesting clinician to acknowledge and act on test results
(Ireland and the US). The NHS has neither the resource and technical uniformity to make an
electronic workflow fool-proof and does not have a track record of taking action in clear failures of
NPSA 16.
There is plenty of commentary online — a couple samples have been selected (and are enclosed)
for HM Coroners ease of reference below:
http://www. pacsqroup.org.uk/forum/messages/2/79236.html (EXH 4)
https://Awww.rcr.ac.uk/posts/patients-risk-lack-systems-communicating-abnormal-imaging-test-
results (EXH 5)
In addition RCR’s Standards for the communication of radiological reports and fail-safe alert
notification (2016) which contains 10 recommended standards, and which the Trust is working
towards.
httos:/Awww.rcr.ac.uk/system/files/publication/field_publication_files/bfcr164_failsafe.pdf
(EXH 6).
The Trust has asked the NHS Benchmarking Network to consider compliance with implementation
of the standards in this year’s census.
| hope that the above reassures HM Coroner and the family that whilst the communication of
incidental radiological results, and those outside cancer pathologies remains a problem nationally,
that the use of ICE and our Guidance will work in tandem to greatly reduce the risk of a future death
like Mr Higgs’ from occurring again at our hospital.
If | can be of further assistance please do not hesitate to contact me.
Yours sincerely
Kit ob
Dr Richard Jenkins
Chief Executive
Enc
Page 30f3
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