Dorothy Webb

Our Ref: 2017/18552
Your Ref: Regulation 28 Report

Date:

11th October 2017

Mr Z Siddique
Black Country Coroners Court
Jack Judge House
Halesowen Street
Oldbury
West Midlands
B69 3AJ

Waisall Healthcare Ij

Trust Headquarters
Walsall Healthcare NHS Trust
Manor Hospital
Moat Road
Walsall
West Midlands
WS2 9PS

Tel:
Email:
Website:

01922 721172 ext 6263/7481

www walsallhealthcare nhs uk

Dear Mr Siddique,

Re:

Dorothy Webb (Deceased)

Date of Birth:
Date of Death:
Date of Inquest:

05/03/1933
05/05/2017
16th August 2017

I am writing in response to your report under paragraph 7, Schedule 5, of the Coroners and
Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.

The conclusion of the inquest was natural causes but evidence emerged during the inquest
of a missed opportunity to assess a scan which would have resulted in further identification
of a “mass” and a failure to note a fracture from an x-ray during a previous admission. The
investigation was unfortunately not complete at the time the inquest was held and I
apologise for this. The report has now been completed and the findings and resulting actions
have been used in my response to you. The Serious Incident investigation process has been
amended with an expectation that investigation reports will be completed wherever possible
before future inquests.

Circumstances of Dorothy Webb’s death

I Around December 2016, Mrs Webb’s health began to decline and she was

experiencing dizziness and had lost consciousness. She was admitted to Walsall
Manor Hospital with a suspected stroke and a diagnosis of hyponatraemia (low
sodium levels) and syndrome of inappropriate secretion of antidiuretic hormone
diagnosed, She was later discharged on the 27 January 2017.

2. On 2 February 2017. she attended the same hospital after a fall. An x-ray was done

and no fracture noted at the time,
The next hospital admiss on came n Apr 1 2
h a o y
expressive dysphasia and a transient ischaemic attack (TIA) was susoected She

7 vhen she p es

te Mt

 was treated and also commenced on antibiotics for a urinary tract infection before
discharge.

4. She was re-admitted back to hospital on the 25 April after a further fall and on this

occasion a fracture (wedge fracture at Ti 2) was identified. Two CT scans were done
but only one scan was examined by the Radiologist and consequently a right para
vertebral soft tissue mass on the CT scan wasn’t identified.

5. On the 2 May she complained of chest pain and troponin levels were mildly elevated.

She was found to be hypertensive and this was treated.

6. On the 4 and 5 May, she had several episodes of coffee ground vomit and at around
20:40 hrs. on the 5 May, she deteriorated rapidly and had vomited a round 500ml of
coffee ground vomit which she immediately aspirated.

7. An emergency response was initiated and the suction machine used was ineffective
but the Doctor treating her at the time does not believe she would have survived
even if the suction machine had been effective because she was very frail and had
very poor physiological reserves.

8. She sadly passed away a short time later.
9 After post-mortem. the tissue mass identified in the scan was confirmed as small cell
carcinoma of Right Lung with Liver Metastases. This type of cancer is particularly
aggressive and very difficult to treat and had spread from the lungs to the liver.

10. The immediate cause of death was heametemisis (vomiting of blood) in conjunction
with aspiration blood-stained vomit/gastric contents into the blood.
There was
evidence of a small distal oesophageal mucosal tear from episode of retching and
vomiting. The low blood sodium levels and the development of
inappropriate
antidiuretic hormone secretion can be caused by the small cell carcinoma.

Coroner’s concerns

During the course of the inquest the evidence revealed matters giving rise to concern and a
risk that future deaths will occur unless action is taken.

The MATTERS OF CONCERN were identified as follows. —

1 Evidence emerged during the inquest that there was a missed opportunity and failure

by the Radiologist to assess the scan which would have resulted in further
investigation of the “mass” that was identified. Although this may not, on the balance
of probability prevented the outcome. it may well have resulted in further medical
investigation and treatment.

2. There was also a failure to note a fracture from the x-ray during the admission in
February 2017 and consequently the patient and family were unaware of its
existence until the re-admission in April 2017

Preventing Future Deaths — Action for Walsall Healthcare NHS Trust

Specific areas for action were identified at the conclusion of the Inquest and a Preventing
Future Deaths report has been issued to the Trust:

1

In relation to the failure to note the scan results you may conside re-visiting your
procedures and systems to ens re thst this is not r phcated as part
serious incident investiqaton.

r nt rn

f y

 As part of the Serious Incident Investigation (provided with this letter) we identified the
following issues and contributory factors:

Issues Identified

•

•

Individual reporter errors in failure to review previous investigations with a high
degree of suspicion to aid in identification of issue.
Presentation of images and reports discrepancy between CRIS and PACS causing
images of T-Spine to not be reviewed by reporter.

Contributory Factors

•

Failure to use urgent red flag notification on CT spine 02/02/2017 regarding
depression of Ti 2 in spine to alert clinicians to report.

• Composition of images making interpretation difficult due to patient factors such as

positioning.

Another finding relates to the delay in providing a Serious Incident report before the inquest.
From now onwards, where a complaint letter suggests that a case might also be an incident;
this will be taken to the next SI meeting for a decision. Whenever there is a multi-stemmed
case, for example a complaint is also an incident and has been listed for an inquest, we will
hold an initial meeting to work out the timeline and responsibilities for each team so that
there is a plan to deliver the investigation and report without unnecessary gaps. Our aim is to
complete an investigation before the Inquest is held so that we can discuss the findings with
the family and also provide the completed report to you in good time.

Actions Taken

The following are the key actions taken in response to this incident in order to improve the
reliability and safety of our systems and minimise the risk of further incidents:

•

To ensure the system for imaging discrepancy and error rate monitoring is robust to
assure that individual errors in reporting are monitored to ensure they are in
accordance with Royal College guidelines and identify individual training issues
which require further support we have established individual Consultant Radiologists
error and discrepancy monitoring rate to highlight practice issues and where training
and development is required.

• The CR15 and PACS records presented in a different order — CRIS (the Radiologist’s
reporting system) shows the images in newest to oldest order while PACS (the
system that holds the images) shows in the oldest to newest order. The PACS
manager investigated whether the system could be configured to reverse the order of
image presentation to match CRIS. It cannot so additional training has been provided
to all reporters.

•

To ensure that the red flag system is used where it is required regardless of referrer
or modality, colleagues have been provided with feedback from this incident and
reminded to follow the policy.

• A review of the individual’s practice was undertaken and the error rate was below

that which requires remedial action.

 • A Lessons Learned’ buileting has been produced to use this incident to remind

clinicians across the trust of their professional responsibility to review and act on all
requested investigations regardless of if they are identified as being urgent.

Finally, and on behalf of the Trust, I would like to take the opportunity to offer our sincere
condolences to Dorothy Webb’s family for their loss and apologise for both our failure to
assess the scan which would have resulted in further investigations and the failure to note
the fracture from the x-ray taken during the admission in February 2017.

I trust that the actions set out in this letter will provide you with the assurance that we have
responded constructively and with the seriousness required to improve the care we provide.

Yourk3cerely

/

I

F

—F—

Richard Kirby
Chief Executive