Michael Halfpenny

~ `,p ~ 
i t

T'  t

University Hospitals
of Leicester
~ws ~rus~

L~ice~ti~r  ~y~l Ir►firrr'ary
Chief Executive's Corridor
Level 3, Balmoral Building
Infirmary Square
Leicester
LE1 5WW
Tel:  0116 258 8940

25 July 2017

Our Ref: JA/mj/MD/AOC/MH

Mrs C E Mason
H. M. Coroner,
Leicester City and South Leicestershire
Town Hall
Town Hall Square
Leicester
LW1 9BG

Dear Mrs Mason

Ref: Michael John Halfpenny

write with  respect  to the Regulation 28 letter  sent  by  your  Assistant  Coroner,  Mrs
Brown, on 1St June 2017 and the concerns detailed therein relating to the University
Hospitals of Leicester NHS Trust, which I accept.

can  confirm  that  we  have  taken  immediate  actions  to  remedy  the  safety  matters

identified and I will now detail these actions:-

We  have  reviewed  the  process  for  rejecting  imaging  within  the  Trust.  The
guideline  'Process for  the  Rejection of Imaging Referrals'  is  being  strengthened
and  updated  and will now include an explicit requirement  that  rejected referrals
need  to  have  a  clear  statement  of  why  the  rejection  has  been  made  and  a
comment must be  put on CRIS (the Radiology IT  system) that  a  rejection letter
has  been  sent  to  the  referrer.  This  is  being. led  by  our  Service  Manager  for
Imaging and it is anticipated that this guideline will be available by the end of July
2017.

2.  We  have  implemented  a  new  system  for  redirecting  any  imaging  referrals  that
inadvertently  get  sent  to  the  incorrect  team.  The  Imaging  Team,  led  by  the
Clinical  Director 
Imaging,  has  provided  clear 
their
administration  and  clerical  staff  to  forward  screening  requests  to  the  relevant
service.  A rejection letter will be sent to the referrer detailing the action that has
been taken and any further actions required by them.

instructions 

for 

to 

University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester
Royal Infirmary.
Website:  www.leicestershospitals.nhs.uk
Chairman: Mr Karamjit Singh CBE  Chief Executive:  Mr John Adler

Cont'd .....

 3.  With respect to the UHL Screening Committee, this group was established in
January 2017 to provide oversight and governance to the increasing number of
national screening programmes now in place, This committee was therefore not
in place at the point that the request from the GP regarding Mr Halfpenny was
made to the Trust.  A key function of this Committee is to review the process of
referrals, the validity of rejected cases (i.e. those that fall outside the scope of the
screening programme) and of course, any incidents reported relating to screening
programmes.  This committee  will  augment the  rigorous  quality  assurance
element already required for screening programmes which is monitored by the
Regional Screening Group.

I n addition to the above our Head of GP Services has sent out a new communication
to GPs in our monthly GP newsletter to explicitly inform them of how to refer in to the
Screening Programrne;~~:ay~.s~:,_;

The Vascular Service  is  also  planning  to  attend  GP Protected  Learning  Time
sessions to  raise  awareness.  This  will  be  overseen  by our  AAA Screening
Programme Manager, and it is anticipated that this will be a rolling programme which
will  have commenced by the end of July 2017. Furthermore, local GPs use a system
called PRISM which is a desktop application integrated into their electronic records
that provide referral guidance. Our Associate Medical Director,
working in collaboration with Primary Care colleagues, will arrange for the referral
pathways for AAA patients to be added onto this system so that this information can
be easily accessed at the point of patient care. It is anticipated that this will also have
occurred by the end of August 2017.

trust this  response assures you that we have taken immediate and extensive
actions and that we are working with internal colleagues and external partners to
safeguard future users of the service.

Yours sincerely

John Adler
Chief Executive

DIGESTER CITI' &
SOUTIi LJCESTERSHIRE
COROiJER~; DISTRICT

2 '1  JUi~ 2017

University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester
Royal Infirmary.
Website: www.leicestershospitals.nhs.uk
Chairman: Mr Karamjit Singh CBE  Chief Executive; Mr John Adler

East L.e~cestershire and Ruflanc~ 
Clinical Commissioning Group 

~~ 

~ 

~" 

From the office of:

n, Chief Nurse &Quality Officer/Deputy MD 

CCG Headquarters 
Leicestershire County Council 
Room G30,Pen Lloyd Building 
County Hall, Glenfield 
Leicester LE38T6 
Web: www.eastleicestershireandrutlandccg.nhs.uk 

22nd September 2017 

Private &Confidential 
H.M. Coroner 
The Town Hall 
Town Hall Square 
Leicester 
LE1 9BG 

Dear Mrs Mason 

Re: Michael John HALFPENNY 

Please find enclosed the signed final report regarding the Serious Incident investigation into 
this case. I  can confirm that we have contacted the family the share the report.  UHL have 
already shared their findings in relation to incident 2. The final report will also be shared with 
UHL to add timescales to their recommendations. 

Please accept my apologies for the delay, if you require any further information please let us 
know. 

Yours sincerely 

Chief Nurse &Quality Officer/Deputy Managing Director 

Enc. SI report

THE GLENFIELD SURGERY 

~~ 
__>~ 

23rd June 2016 

~-

STRICTLY PRIVATE &CONFIDENTIAL 
TO BE OPENED BY ADDRESSEE ONLY 
Mrs L C Brown 
Assistant Coroner 
Leicester City and South Leicestershire 
The Town Hall, Town Hall Square 
Leicester 
LE1 9BG 

Dear Mrs Brown, 

Re: Michael J Halfpenny 

I 

1" 

~,`~C~~~ -~  c Ds 

~~ 

2~(6(I~-

I am writing to you to submit further evidence to you on Mr Halfpenny's inquest. 

The matter has been fully discussed with all practitioners in the practice however, it was my 
colleague

 who saw Mr Halfpenny and requested the ultrasound. 

He has reflected on his involvement in  Mr Halfpenny's care and has himself produced a 
significant event analysis.  He has also written to the Radiology Department. 

I enclose his SEA, rejection letter from Radiology and his letter to Dr Rodgers, Radiologist 
who rejected the referral. 

I also wish to advise that I have discussed the matter with my colleagues at the CCG and 
this incident has been accelerated to ~~a  serious incident" and will invoke a formal multi-
agency review. 

Yours sincerely 

Encs: SEA; rejection letter; Letter to Radiology 

111 STATION ROAD,GLENFIELD,LEICESTER,LE3 SGS 
Telephone 0116 2333600  Fax(Medical)0116 2333602 

 
 
 
 
 
 
 
 
 
 
 Significant Event Audit Record 

Date of Audit 

19.06.2017 

Reporter 

JWT

Initials ofPatient 

MH 

Patient Code 

Date ofIncident: 09.12.2016 

Incident Description: MH was a 77 year old man who presented to myself on 23.03.2016 with a productive 
cough,SOB and some wheeze in the evenings. I found, on examining him, he had some crepitations in the right side 
of his chest and duly prescribed him Amoxicillin (5 day course) for a chest infection.  As he was leaving the room, 
MH mentioned to me that both brothers had aortic aneurysms diagnosed and had been treated for these. I decided that 
instead of booking him another appointment, to save time, I would refer him for an USS to check on this aortic 
aneurysm and I sent this to Glenfield Hospital, USS Department on 23.03.2016. In my clinical history, I explained 
that both his brothers had aortic aneurysms at the same age as the patient was then and that both had repair operations 
although, at this point he had no symptoms, I explained that given his history he needed screening for aortic 
aneurysm. 3 weeks later, on 14`" April, the request was rejected by
, Consultant Radiologist at Glenfield 
Hospital.  However, we did not receive the rejection unti125`h April. In all approximately 1 month from my original 
referral before we knew it had been rejected.  At which point, I remember arranging a telephone appointment with 
MH for 29.04.2017 to discuss this. For some reason MH was not available and I commented on the record that I left a 
message on the answerphone. Unfortunately,for a reason I cannot explain, I did not further up on this at this point in 
time and it was then many months later when he presented to one of my pairtners, NC on 9.12.2016 with abdominal 
pain. MH was clearly unwell,clammy and appeared to be in severe pain. MH was in a dreadful state so my colleague 
arranged a 999 ambulance and he was duly taken to the LRI. The ambulance crew were working on a diagnosis of 
renal colic and administered Morphine. The casualty department was full and the patient then spent 1 '/2 hrs in the car 
park awaiting admission into the LRI.  Subsequent events followed on from this and the patient ultimately passed 
away with a ruptured aortic aneurysm. A Coroner's inquest was held and at the time, it was my partner, NC who was 
asked to produce a report which he duly did but which focused on his involvement around the referral ofthe patient. 
He did not look further back to make any connection from the patient's previous history, up to the point before the 
day of the inquest when he reviewed the records more thoroughly and at which point he noticed the patient had 
presented to me with a chest infection but that having mentioned the patient's family history of aortic aneurysm, he 
had seen that I had referred him for an USS via Anglia Ice and that this had subsequently been declined by the 
hospital as "Screening not offered" 

Discussion Points (issues raised): Men in the UK have an USS for AAA in the year that they turn 65. I think 
the screening programme started after this patient was 65 however,through my colleagues research, we became aware 
that patients who have a strong family history of aortic aneurysm can contact the screening department by ringing 
them directly or be referred directly for screening via their GP. In retrospect, when I saw this patient back in March,I 
recall seeing him very briefly at the door for the issue around his aneurysm and duly sent off the referral.  It is true 
that I wasn't aware that he should have gone via the screening service and that had he been seen in the normal 
screening manner then his aneurysm may have been picked up and ri~eatment received, which could have saved his 
life.  Having received the rejection form, I arranged to speak to the patient about this but this conversation never 
happened and as a result was a failed telephone contact. I do not know why I did not pursue the patient beyond this 
and I can't explain this even now. It is my normal practice to act upon any rejection letters and failure to do so is very 
unusual for me.  Had the patient been refen~ed via 
 to the AAA screening service having received a 
perfectly clear indication of why I felt he warranted the USS,then the USS would have taken place as I had originally 
 could have highlighted his reasons for rejection and at the same time sign-posted him 
hoped. I do feel 
onto the appropriate AAA screening service or at least made it  very clear to me in his rejection that this patient 
warranted referral onto the AAA screening service in a more clear way.  In this patient's case the true significant 
event was the delay in admitting him into casualty which was unfortunate and was beyond the control ofus as GPs. A 
poll of the clinicians in the practice was also a quick way of identifying the lack of knowledge amongst my fellow 
clinicians ofthe availability of AAA screening and the method by which patients should be referred to this service. 

 
 Agreed Action Points: 
NC originally brought up this case for discussion in our practice meeting. 
Obviously following which,I was then able to investigate my involvement 
in the case. I have reflected on how aortic aneurysm should be 
investigated and have written with my own concerns about the Radiology 
Departments dealing ofmy referral in the hope they will reflect upon this 
and reach their own lessons on this tragic case. I have discussed the case 
with my partners and have provided this SEA to be sent with my 
colleagues report to the Coroner. I will ensure a copy ofthis and my 
letter to

. 

I will alter the way I deal with failed telephone appointments to include 
sending the patient an SMS message which will show what advice I have 
given the patient in terms offollowing up on the missed call which should 
make the process much more robust. 

We will produce some posters to put up in our waiting rooms to encourage 
any patients with a family history ofaortic aneurysm to self-refer for 
screening and we have also mentioned this to our PPG who produce a 
regular newsletter for inclusion. 

When sending a copy of my SEA to the Coroner, I will also include the 
photocopied rejection from the Radiology department. 

I will be discussing this SEA with my appraiser at my next appraisal. 

Having been informed of my involvement in this tragic event,I have felt 
compelled to arrange a meeting with Mrs Halfpenny to express my regret 
and explain my involvement in his care process. 

Responsible Person: 

All doctors to be aware ofself-
referrals so they can sign-post 
appropriate risk patients. 

Our Operations Officer and Patient 
Services Manager to arrange for an 
appropriate poster(possibly to obtain 
one from the AAA Screening Dept) 
and liaise with our PPG so they are 
able to include an item in their 
newsletter 

 
 
 THE GLENFIELI)SURGERY 

,-l 

22 Jun 2017 

Dr P Rogers 
Consultant Radiologist
Department of Radiology
Glenfield Hospital
Groby Road 
Leicester 
LE39QP 

Re  Mr Michael Halfpenny D.O.B.27 Sep 1939

Dear Dr Rogers, 

am writing to you concerning a patient at the surgery, Mr Michael Halfpenny.  Back in
March, I  saw him  regarding  a chest infection  and as he was leaving  my room  he
mentioned to me he had a strong family history of aortic aneurysms.  In fact his brothers
had both had aortic aneurysm repairs at the same age. He was asymptomatic but I felt he
needed screening. 

referred him to the ultrasound department on 23rd  March 2016.  It  was noted that the
request was received by
 on 23~d March 2016 but it was passed for a comment and
was rejected by yourself on 14th April 2016.  However, we did not receive the letter of
rejection until 25t" April 2016.  Mr Halfpenny was rejected on the basis that `no screening
was offered'. 

Mr Halfpenny, at the age of 76, had missed the National Screening Programme.  The
patient in question went on to develop abdominal pain and subsequently died of a ruptured
aortic aneurysm on the 24th January 2017. 

His death has been a matter for the Coroner and one of my partners attended an inquest
where several issues were raised. One issue was that the practice had not been aware of
the screening structure for aortic aneurysm locally and that we had not received any
leaflets or posters from the screening department in order to communicate the screening
to patients. As a result, we have taken the liberty of designing our own posters to display
in the building. 

111 STATION ROAD,GLENFIELD,LEICESTER,LE38GS 
Telephone 0116 2333600 Fax(Medical)0116 2333602 

 
 
 
 
 
 
 
 
 
 
 When the letter of rejection was received, unfortunately no action was taken.  I  am unable 
to explain why this happened because I  am normally attentive to any rejections from the 
department, but obviously we do deal with many reports and results and this one appears 
to have slipped through. As a result of this occurrence, I  took a straw poll of my partners 
and found that of the 5 doctors within  our immediate  practice, there was very little 
awareness of any confirmed route of referral for aortic aneurysm screening.  I  know this is 
only a small number of clinicians however, I  think it  does highlight a potential problem 
within the general practice community. 

As a result of this tragic incident, I  have had to reflect on my personal involvement in this 
case but it does appear from our discussions on this that there are issues that we feel the 
Radiology department need to be able to reflect upon. 

The patient saw me for an entire different reason and this was an addendum to the 
consultation.  Rather than deferring this discussion to another point, I  thought I  would be 
helpful in sending in a request for an ultrasound scan. 

had enclosed pretty clear clinical reasoning behind the reason for the screening and I  feel 
that simply to  have this request rejected  was particularly  unhelpful given the serious, 
underlying clinical implication. 

As GPs we are required to deal with many health matters. We are not specialist radiology 
trained clinicians and we rely upon our secondary care clinicians with specialist knowledge 
in radiological investigative areas. Given a particular clinical need, we would expect some 
guidance as to the appropriateness or inappropriateness of a referral but with some sign-
posting as to where the referral should be directed if not to that department and also of any 
further tests that are now available that we could avail ourselves of. 

At the heart of the issue, it is a patient and the patient had a clinical need. All of us are 
surely working towards this and in the spirit of co-operation, I  feel you should have given 
some clarification  as to where he should  have then  been sent, or it  does not seem 
unreasonable that the  request could  have been passed  directly  through to the AAA 
screening department within Glenfield Hospital. 

Some form of sign-posting would have made his screening omission less likely and indeed 
had the original referral been passed through to the screening department, then obviously 
he would have received the necessary screening and this event may well not have taken 
place. 

Whilst I  accept my responsibility within this, I  do feel that we cannot know everything about 
everything and in an ideal world, yes, that would be possible however, reality is that there 
are certain areas where we might well have ideas of the possible routes of referral but to 
some extent rely upon our secondary care colleagues to point us in the new direction if 
that is deemed necessary. 

 Obviously, this tragic case has caused all of us to read up about the screening and ask 
searching questions as a result of which, I  have personally completed an SEA.  My 
partner, 
, who is Chair of the Leicester Medical Committee has included an 
article in the LMCs newsletter to disseminate learning to the entire GP community. He has 
also written a formal report for the Coroner detailing his involvement and including a copy 
of my letter to yourselves as well as my SEA report. 

think that an issue of this magnitude should cause all of us to reflect on how we could 
have done better by the patient and I  would be grateful fi  you could reflect upon these 
comments with your colleagues in the department. 

This situation should not have occurred and I  feel that we can, with co-operative working, 
prevent this happening again in the future. 

Many thanks. 

Yours sincerely 

 ~q 

INITIAL
~FfQW TC? 

-.._,~.

Jeanessa27 Apr 201611:15

fE~.~

~ I  THo~ itals of Leicester  ~jT~~~ 

NHS Trust 

~`~~.~ F~AT1~N°~ 
NOt~I~/~L 

t

Radiology C7eparkment 
University Hospitals of Leicester

Telephone 011  258 8765 Option 4 

Glen~eld Surgery 
111 Station Road 
Glenfieid 
Leicester 
LE38GS 

Dear

Date; 22 Aprii 2016 

We have received a referral ~n the 14/0 /16 tc~ make an appointment for the following patient. 
Patienx: Mr Michae{ J Halfpenny  ~~t~ of birth: ~7109i1939 

{  ~°

the test

Examination: US Abdominal aorta 
Unfortunately, we are unable to proceed with this request at this time anti must return it to you 
far the following reason: 
Insufficient clinical ~  Yt~`~t~Kru 
A recentlprevious report answers the clinical question an the request 
Patient did not make contact 
Clarification is required as to tlis required tt~a timescale for the test 
Signature illegible -unable to indentify referrer 
And/ other reasons for request rejec#ion: 

() 

() 

()

Any further comments about rejection: 

Please r~tum a complete referral farm via your normal route. 
We appreciate your support with this request and would like tc~ offer our apologies far any 
inconvenience caused. 

Yours sincerely, 

On behalf of Radiology C~eparkment. 

~-18463058  Iltllllllll1111~~llllillll~lllll~l~illlili~lllill~~~11141111 

Trust Headquarters, Levet 3, Balmoral 8uii~iin~, L~iceste~ Ftayal Infingary, 

halrman Mr Kat~amiitsin9l~ Chin{ Exacutive Mr John Adlar 

Mr Michael Halfpenny, printed 22 Jun 2017 14:55(page 1 of 1) 

 
 
 
 
 
 
 
 
 
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E-1846305$ 

~~~~~~~~~V~1~~1~~~~~~~1~~~~~1~~~~~~~~1~~~~~~l~~~~I~~~~~~~~~) 

Mr Michael Halfpenny, printed 22 Jun 2017 14:55(page 1 of 1) 

 
 ~~ 

THE 
GLENFIELD 
SURGERY 

13t"June 2016 

STRICTLY PRIVATE &CONFIDENTIAL 
TO BE OPENED BY ADDRESSEE ONLY 
Mrs L C Brown 
Assistant Coroner 
Leicester City and South Leicestershire 
The Town Hall 
Town Hall Square 
Leicester 
LE1 9BG 

Dear Mrs Brown, 

Re: Michael 7 Halfpenny 

I am responding further to your request for a response to your report of 
Regulation 28. 

I can confirm that after attending the inquest, I wrote up the case as a 
significant event and the practice has taken a number of actions to try and 
prevent such a circumstance in future. 

Our Managers have been in touch with the Aortic Screening Department and 
have confirmed that men over 65 who have missed a National Screening 
Programme can self-refer and that patients under the age of b5 who have a 
family history of aortic aneurysms can be referred by the practice. 

The screening department does not produce any appropriate communication 
materials with patients and the practice has taken the liberty of designing its 
own posters for display in the building.  We have also had a discussion with 
our Patient Participation Group v~~h9c~ will  be incl~!ding ~n ~;rticle in tl~~ r~axt 
edition  of the  newsletter  and  we are  displaying  the information  on our 
television screens within the waiting areas. 

In order to disseminate learning to the wider GP community, I have taken 
the liberty of including a significant event analysis to our locality group which 
includes a number of practices that work within the South  Leicestershire 
area. 

111 STATION ROAD,GLENFIELD,LEICESTER,LE38GS 
Telephone 0116 2333600  Fax(Medical)0116 2333602 

 
 
 
 
 
 
 
 
 
 
 
 
 
 As Chair of the LMC, I am also intending to include an article in the LMC 
(Local Medical Committee) newsletter to disseminate learning to the entire 
GP community within Leicestershire. 

For your information, I enclose a copy of our significant audit report, the 
posters we are intending to display which will be A3 in size. 

Please let me know if there are any further queries. 

Yours sincerely 

Encs 

 
 •~; 

~;, 

~ 

~ 

An aortic aneurysm is an enlargement of the aorta. They usually cause no 
symptoms until they rupture. They are most commonly located in the abdominal area 
aorta, but can be located in the thoracic area. 

Because the abdominal aorta is such a large vessel, a ruptured abdominal aneurysm 
is a life- threatening event 

Screening 

Men aged over 65 are far more likely to have an abdominal aortic aneurysm (AFlA) 
than women or younger men — so any man registered with a GP will receive a letter 
inviting him for a one off screening when he turns 65. 

Men aged over 65 who have not already had a screening can request a scan by 
contacting their local AAA screening service directly on:0116 2586 20 

~i 

...- - • 

Screening involves a simple ultrasound scan of the stomach (abdomen)which takes 
about 10 —15 minutes. 

If you have a family history of AA but you are under 65 and have not been screened, 
your GP can refer you for an ultrasound. 

Please inform the receptionist if you wish to be referred due to a family history. 

-

.-

-

-- -. 

Women and younger men are not invited for screening because 95% of ruptured 
AAAs occurs in men aged 65 and over and it is not part of the national programme. 

   
 Significant Event Audit Record 

Date of Audit 

28.5.2016

Reporter 

NC 

Initials ofPatient 

Mx 

Patient Code 

Date ofIncident  9.12.2016 

Incident Description: 
MH was a 77 year old man who presented to me as the On Call Doctor on Friday 9"' December 2016. Using 
telephone triage and his wife booked an appointment at 16.50, I spoke to her at 17.20 and she said her husband had 
significant abdominal pain and she was thinking oftaking him to casualty. As I could see him 
suggested he come to the surgery and I saw him at 17.30. When I saw him he was clearly unwell,clammy and 
complaining ofleft loin pain. He looked dreadful so I arranged for reception to calla 999 Ambulance and he was 
duly taken into the Leicester Royal Infirmary. The Ambulance were using a working diagnosis ofrenal colic and 
administered Morphine. The casualty at the Royal Infirmary was full and the patient spent 1 '/2 hours in the car park 
awaiting entry into the Infirmary. Subsequent events followed and this patient ultimately passed away with a ruptured 
aortic aneurism. A Coroner's inquest was held whereby I had to produce a report. I focused on my personal contact 
with him in my report however the day before the inquest I made a more thorough analysis from this patient's record. 
In March 2016 he presented to a colleague with symptoms ofa chest infection but the patient mentioned that he had a 
strong family history ofaortic aneurism(both his brothers had them repaired)and the examining doctor requesting an 
uss 

via Anglia Ice. However this uss request was declined by the hospital as "screening not offered".

more quickly I

Discussion Points(issues raised): 
Men in the UK have an uss for AAA in the year they turn 65. I think the screening programme started after this 
patient was 65. However through my research I became aware that patients who have a strong family history ofAA 
can contact the screening department either themselves or via their GP and can be included in the screening scans. 
I think the doctor whom he saw in March 2016 was not aware ofthis and hence did not signpost the patient 
appropriately. It is possible that had he signposted the patient for the AA scan his life would have ultimately have 
been saved. In this patient's case however the true significant event is the delay in admitting him into casualty which 
was beyond the control ofus as GPs. 

Agreed Action Points: 
I brought up this case as a discussion point in our practice 
meeting. 
We will produce some posters to put up in our waiting room 
to encourage any patients with a family history ofAA to self 
refer for screening and we will also mention this fact to our 
PPG wha profiace a regular newsletter for inclusion within 
their newsletter. 

Responsible Person: 
All drs to be aware ofself 
referrals so they can signpost 
appropriate risk pts. Our 
operations manager &patient 
services manager to arrange 
for an appropriate poster 
(possibly to get one fi•om the 
screening dept &also liaise 
with om•PPG so they can 
include an item in their newsletter 

 
 
 LEICEST'.-R CITI'& 
SOI!T 1 i  EKES'ERSHIRC-
CORGNERS DISTRICT 

1 4 JUN 2017