Harold Chapman

ANNEX A

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. Brompton NHS Trust

1 | CORONER

1 am Dr Julian Morris, assistant coroner, for the coroner area of Inner London South

2 | CORONER'S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
[HYPERLINKS]

3 | INVESTIGATION and INQUEST

An investigation into the death of Mr Harold Chapman, who died on 14 June 2016 was
opened. The investigation concluded at the end of the inquest on 27 October 2017. The
conclusion of the inquest was :

that Mr Chapman died as a result of natural causes but that the care provided to
him in/around August and November 2015 was such that it amounted to a gross
failure to provide basic care for his condition and his risk stratification and the
subsequent insertion of an ICD to treat and prevent a sudden cardiac death
incident.

4 | CIRCUMSTANCES OF THE DEATH

Mr Chapman had been diagnosed with Hypertrophic Cardiomyopathy (HCM) in
2009, and referred to a specialist team in 2010. His reviews and treatment from
early 2010 to May 2015 were unremarkable and his risk stratification was low.
In August 2015, he developed non-sustained ventricular tachycardia (NSVT)
present in 2 holter readings (August and December 2015). The consultant
requesting the August trace did not review it. It was reviewed by a clinical
fellow in November 2015 who considered it to be unequivocal. Subsequent
review in 2016 confirmed the presence of NSVT and a significant increase to Mr
Chapman’s risk factors for an episode of a more significant arrhythmia and
subsequent sudden cardiac death.

A further holter trace in December 2015 also revealed NSVT; this was not
reviewed until it was seen by a new team in April 2016. Following the review in
April 2016, he was referred for consideration of an ICD implant which would
deliver a shock should he develop sudden arrhythmia (ventricular tachycardia or

ventricular fibrillation). The chances of survival of an out of hospital cardiac
arrest were low. His risk stratification in April 2016 was 8.7% and warranted
consideration of the implant.

The Trust were aware of Mr Chapman’s condition and its possible complication
having been central to the development and implementation of the ESC
Guidelines in 2014 on the management and treatment of individuals with HCM.
The development of NSVTs increases an individual’s risk stratification and the
percentage chance of having a sudden cardiac death arrhythmia. Such an
arrhythmia can only be treated by way of delivery of an electrical shock. Ifa
shock is not delivered within minutes the chances of survival are low. The ICD
delivers that shock.

The waiting time for an ICD insertion, having passed through the various
reviews and assessments around the time of Mr Chapman’s death was 6 months.
Following the holter trace in August 2015, this was not reviewed by the
consultant; it showed a run of NSVT. He was reviewed in the clinic in
November 2015, it was deemed unequivocal. No action was taken and the
failure had a direct and clear causal connection with Mr Chapman’s death.
Statistically there was no way of knowing if and when Mr Chapman might have
had a significant arrhythmia. At the time of his death he had opted for and was
on the waiting list for assessment of an ICD following review of the same
August trace. In all the circumstances the missed opportunity more than
minimally, negligibly or trivially contributed to Mr Chapman’s death. Rendering
that treatment, at the earlier time would, on balance, have saved Mr Chapman’s
life when he had the arrhythmia in June 2016.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise 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 MATTERS OF CONCERN are as follows. —

(1) the consultant responsible for Mr Chapman’s care in August and November 2015
was based, at the time, at Barts NHS Trust and is now employed by the Brompton.
The consultant was responsible for reviewing the investigations that he (and other
members of his team in their absence) had requested.

(2) There appeared to be no check mechanisms in place to ensure that this was done
and appropriate action taken in line with the Guidelines..

(3) There was also a concern in respect of the holter interpretations and the presence
or otherwise of NSVTs on the traces. Barts NHS Trust have instigated a new
introduction and training regime for its specialist clinical fellows in the interpretation
of holter readings.

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.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by Wednesday 13" February 2017. |, 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.

COPIES and PUBLICATION

Ihave s t to the Chief Coroner and to the following Interested
Persons|

| 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.

28 November 2017 Dr Julian Morris

Date: 31 January 2018 

Private and Confidential 

Trust Executive Office 
Ground Floor 
Pathology and Pharmacy Building 
The Royal London Hospital 
80 Newark Street 
London E1 2ES 

Telephone 020 3416 5000 

www.bartshealth.nhs.uk 

Dear Dr Julian Morris 

Mr Harold Chapman came under the care of the Heart Hospital (University College London 
Healthcare Trust) in 2009 following a diagnosis of hypertrophic cardiomyopathy. Following the 
merger of the Heart Hospital with Barts Health Trust cardiac services in 2015 his care was 
transferred to Barts Heart Centre. 

The Inherited Diseases service at Barts Heart Centre (BHC) manages up to 10,000 outpatient 
episodes per year and manages elective and emergency inpatients. The team includes a core group 
of 6 consultants, 5 clinical nurse specialists, 2 genetic counsellors, and 3 dedicated clinical fellows 
along with variable numbers of research fellows and training SpRs. Each week, the team complete 
more than 40 clinics, of which half are face-face with the consultant. 

At diagnosis, Mr Chapman’s condition was assessed as low risk, and this situation remained through 
to 2015 when he was first seen at BHC. At this time his test results, along with his clinical symptoms, 
indicated an increase in risk that should have led to referral for an Implantable Cardiac Defibrillator 
(ICD)  but  this  was  not  recognised  by  the  clinicians  involved  in  his  care.  In  April  2016  his  risk  was 
formally  assessed  and  he  was  referred  to  the  multi-disciplinary  team  meeting  for  consideration  of 
ICD  implantation.  There  was  a  considerable  backlog  with  the  MDT  at  that  time,  the  waiting  list  for 
discussion  was  2-3  months.  Mr  Chapman  made  efforts  to  chase  the  team,  mainly  through  email 
correspondence with the clinical nurse specialist, to gain a conclusion as to his need for an ICD but 
he sadly suffered a sudden cardiac death in June 2016 before the matter was concluded.  

A serious incident was reported by BHC following confirmation of the cause of Mr Chapman’s death. 
An investigation was led by Dr Saidi Mohiddin, a consultant with the inherited diseases team but not 
personally involved with Mr Chapman’s care. The investigation concluded that the root cause of Mr 
Chapman’s death was the failure to recognise and action the risk factors for SCD presented by the 
patient  in  2015.  At  this  time  there  were  established  guidelines  for  the  assessment  of  the  risk  of 
sudden  cardiac  death,  however  there  was  no  mandated  local  policy  for  use  of  a  formal  risk 
assessment tool.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The  service has  taken  action following  the  conclusion  of the  investigation to  improve practice. This 
has included development of a procedural document detailing requirements for SCD risk assessment 
and pathways for escalation to the MDT meeting; adherence to this document is being monitored via 
the  audit  process.  The  MDT  now  meets  twice  weekly  and  the  backlog  has  been  cleared.  The 
pathway document defines the acceptable interval between risk detection and presentation to MDT. 

A complaint was received from Mr Chapman’s widow in August 2016. This letter raised her serious 
concern with regards to the timeliness of care provided to her husband, insufficient risk assessment 
and  lack  of  responsiveness  when  her  husband  was  attempting  to  expedite  his  treatment.  The  site 
upheld Mrs Chapman’s complaint and offered a full apology.  

Following  conclusion  of  Mr  Chapman’s  inquest  in  2017,  a  request  was  received  from  his  family  to 
meet with the staff at BHC. This meeting, chaired by Edward Rowland, BHC Medical Director, was 
held on 22/11/2017. The team were able to offer the family assurance that lessons had been learnt 
from Mr Chapman’s death and practice had changed.  

One  of  the  lessons  learnt  from  the  investigation  of  this  incident  was  the  need  to  ensure that  email 
correspondence  with  patients  must  be  added  to  the  patient’s  health  record.    The  cardiomyopathy 
service has taken action to ensure that this is now done.  

More  widely,  clear  guidance  is  needed  for  all  clinicians  on  their  responsibilities  regarding  email 
communication  with  patients.  Trust  wide  guidelines  are  being  drawn  up,  working  to  the  following 
principles: 

1.  Emails  sent  to  and  from  Barts  Health  clinicians  from  other  clinicians  and/or  patients  which 
contain  clinically  important  information  about  Barts  Health  patients,  must  be  filed  in  the 
patient case notes. 

2.  If Barts Health staff give an email address to patients, then that email box must be monitored 
and  all  e-mails  should  be  seen  and  appropriately  addressed,  within  a  clinically  acceptable 
time period. If such an email address is temporarily not monitored due to leave etc, then the 
out of office message should make this clear. 

3.  The Barts Health website will be reviewed to ensure that patients and referrers know how to 
contact the hospital. If email addresses are published, it will be made explicit when and if the 
address should be used for clinical correspondence. 

4.  Letters  sent  to  patients  and  clinicians  will  routinely  detail  how  the  clinical  team  can  and 

should be contacted. 

Yours sincerely 

Dr Alistair Chesser 
Chief Medical Officer 

2

ae From Caraline Dinenage MP

Minister of State for Cara

Department
of Health 39 Victoria Street
Landon
SW1H OEU
Your Ref: 01620/2016 020 7210 4850
PFD-1112324
Dr Julian Morris
HM Assistant Coroner, Inner London South 22 FEB 2aia

Southwark Coroner’s Court
1 Tennis Street

Southwark

London SEI 1YD

Thank you for your letter of 22 December to Jeremy Hunt about the death of
Mr Harold Chapman. I am responding as Minister with responsibility for
professional regulation.

I was very saddened to read of the circumstances surrounding Mr Chapman’s death.
Please pass my condolences to his family and loved ones. I appreciate this must be a
very difficult time for them.

It was disappointing to learn that, in Mr Chapman’s case, emails sent by Mr
Chapman to his clinicians were not viewed or acted upon and no response was
received by Mr Chapman. As you point out, patient contact with medical
professionals is an important part of modern medical practice, and it is regrettable
that this did not work well in this case.

You ask about guidelines in respect of communication between patients and their
clinicians, My officials have made enquiries and I am able to advise the following.

The General Medical Council (GMC) develops standards and guidance that doctors
need to follow to deliver high quality, safe care. The core professional standards
expected of all doctors are set out in Good Medical Practice which covers
fundamental aspects of a doctor’s role, including communication with patients.

Good Medical Practice was published in 2013 and describes what is expected of all
registered doctors. All doctors must be familiar with and follow Good Medical
Practice and the explanatory guidance. Failure to follow the guidance set out in Good

Medical Practice may put a doctor’s registration at risk. Good Medical Practice is

available at www.gmc-uk.ore/guidance/index.asp.

The following guidance is given in respect of communicating with patients:

Communicate effectively

31, You must listen to patients, take account of their views, and respond honestly to
their questions.

32. You must give patients the information they want or need to know in a way they
can understand. You should make sure that arrangements are made, wherever
possible, to meet patients’ language and communication needs,

33. You must be considerate to those close to the patient and be sensitive and
responsive in giving them information and support.

34, When you are on duty you must be readily accessible to patients and colleagues
seeking information, advice or support.

www.eme-uk.org/guidance/good_medical_practice/communicate_effectively.as
And,
Communicating with patients

132. Wherever possible, you should communicate with patients in a format that suits
them. For example, electronic communications — such as email or text messaging —
can be convenient and can support effective communication between doctors and
patients, with appropriate safeguards,

133. Most communication methods pose some risk of interception ~ for example,
messages left on answering machines can be heard by others and emails can be
insecure, You should take reasonable steps to make sure the communication methods
you use are secure,

www.gme-uk org/guidance/ethical_puidance/30624.asp

In May 2016, NHS England issued guidance for using email and text message for
communicating with patients as part of the Accessible Information Standard.
Although the guidance is intended to support the use of email and text message as
part of communication with people who have a disability, impairment or sensory loss

uy

Department
of Health

(in line with the scope of the Accessible Information Standard), the principles are
applicable in general.

Relevant passages include:

The parameters of how much contact is conducted by email and / or text message
should be agreed, with the service setting clear limits and ensuring that the patient or
service user is aware of them, It is likely that the service will wish to limit two-way
dialogue via email or text message which risks becoming a ‘virtual consultation’ and
instead direct the patient or service user to make an appointment, for example to
discuss test results,

Services, and their staff, should only send emails from generic team accounts (for
example diabetes@lgi.nhs.net / oncology@coch.nhs.uk) and established corporate
text messaging accounts. This ensures that patients / service users can be confident
that the sender is legitimate. Individual staff email addresses should not be used.
Use of generic accounts also ensures that emails and text messages can be accessed
and actioned by multiple members of staff, providing cover in the event of absence.

It is best practice to acknowledge receipt of an email within 24 hours.

Emails are classed as records and should be retained for the appropriate period of
time, Where possible, a copy of the email should be stored in the patient or service
user's record. If this is not possible, then an entry should be written into the patient
or service user's notes detailing the important content of the email and subsequent
actions (for example, blood test dated 24.6.14; results emailed to patient 25,6.14;
patient replied asking for outpatient appointment; booked for 1.7.14 at 14:30). This
covers the interaction with the patient, and the original emails can be found in the
email archive /system if required.

Further information is available at www.england.nhs.uk/ourwork/accessibleinfo/,

As the communication of, and acting upon, test results was an important aspect of
this case, you might also be interested to know the standards the GMC sets for good
patient care apply to all aspects of a doctor’s decision-making, including their
handling of test results and how they communicate with and support their patients.
As well as the standards highlighted above, the following passages have relevance
here:

© Providing a good standard of clinical care (paragraph 15)
Ensuring continuity and effective, safe handover of care (paragraph 44)

e Establishing a partnership and good communication with patients (paragraph
49)

e Supporting patients to self-care including providing information and
answering questions (paragraph 51)

Consistent with these standards, it is expected that the doctor who orders tests as part
of a patient’s care takes responsibility for following up on the test results and ensures
that the results are communicated to the patient in a timely way that meets their need
for reassurance and support.

We also expect doctors to be aware and follow clinical guidelines and other standards
of good practice that relate to their particular area of work (Good Medical Practice
paragraphs 11-12), Additionally, in relation to ordering, following up on and
informing patients about test results, there is specific guidance from NHS England,
the British Medical Association (BMA) and the Royal College of Pathology, all of
which address the concerns raised in this case,

In March 2016, NHS England published a set of standards for the communication of
patient diagnostic test results when they are discharged from hospital, available at
tices/

patients-regarding-test-result . The standards describe acceptable, safe practice
around how diagnostic test results should be communicated between secondary,
primary and social care and also with patients. The intention is to ensure that
hospitals take responsibility for their own tests, and this is specified in the first key
principle, which states the clinician who orders the test is responsible for reviewing,
acting and communicating the result and actions taken to the General Practitioner
and patient even if the patient has been discharged.

The BMA published advice in December 2016 on the duty of care for communicating
test results which supports the NHS England standards, and related advice published

by the former National Patient Safety Agency.

The Royal College of Pathology published guidance on ‘The communication of
critical and unexpected pathology results’ (October 2017) which makes clear that:

Pathology providers have a responsibility to put mechanisms in place that allow the
identification and rapid communication of critical and unexpected laboratory test
results, It would also be expected that pathology providers negotiate with secondary
care clinicians, GPs, other members of the clinical team and out-of-hours primary
care providers to ensure robust mechanisms are in place so that appropriate action is

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Department
of Health

taken following rapid communication of such results. There is also a responsibility
placed upon the users of the service to ensure clear requesting instructions, contact
information and awareness of self-checking of results once requested, in an
appropriate and timely manner. It is also vital that local guidelines are in place,
especially in primary care, to deal with patients with critical results.

It is essential that the NHS learns lessons where things have gone wrong to ensure it
provides safe, high quality care.

My officials have made enquiries with the Barts Health NHS Trust, through NHS
Improvement, and I understand that the cardiomyopathy service has taken steps to
ensure that email communication with patients is included in the patient’s health
record. More widely, I am advised the Trust is working to draw up guidelines on the
responsibilities of clinicians in relation to email communication with patients.

The Barts Health NHS Trust will respond to your report separately and so I will not
include here the detail of the action the Trust has taken in relation to this case.
However, I am assured that the Trust conducted a serious incident investigation into
Mr Chapman’s death and that recommendations from that report are being taken
forward to improve practice.

I hope this information is helpful and provides assurance that there is guidance
available to clinicians in this area, Where there are concerns about the conduct of an

individual clinician, these should be brought to the attention of the GMC as regulator.

Thank you for bringing the circumstances of Mr Chapman’s death to our attention.

Royal Brompton & Harefield (775)

NHS Foundation Trust

Royal Brompton

12 February, 2018 Hospital
Sydney Street

Her Majesty’s Coroner for inner South District London

Greater London SW3 6NP

Southwark Coroner’s Court T: +44 (0)20 7351 8283

1 Tennis Street

Southwark

LONDON SE1 1YD

Dear Dr Morris

RE: Regulation 28 Reports to Prevent Future Deaths following the inquest touching the death of Harold Chapman
(Date of Death 14.06.2026)

| write in response to two letters dated 19" December 2046 received from your clerk John Thompson in relation to
this matter. | would like to highlight the fact that these letters were addressed to Mrs G Raikes who is the Chief
Executive of the Royal Brompton and Harefield Hospitals charity and not the NHS Hospital Foundation Trust. Hence
there was a delay of some 2 weeks before the Regulation 23 Reports were received by relevant staff in the Trust. An
acknowledgment of receipt was sent tq by email on 02.01.18,

| note two separate Regulation 28 Reports were sent following the, inquest touching the death of Harold Chapman:
the first addressed to Brompton NHS Trust only and the second to the Secretary of State for Health, Barts Health
NHS Trust and Brompton NHS Trust, These documents have been carefully reviewed and | now set out my response
below.

Firstly, | should state that Mr Chapman was at no time a patient under the care and treatment of the Royal
Brompton and Harefield NHS Foundation Trust (RBHT} and unfortunately RBHT had no opportunity to participate in
the inquest or provide information which may have been of assistance in this matter.

I note that HS oven from Bart's Health to RBHT as a consultant cardiologist in December 2015, 6
months prior to Mr Chapman’s death. Our Medical Director and Responsible Officer, Dr Richard Grocott-Mason has
discussed with | this matter and the concerns raised by you at inquest. | am keen to ensure that there are
systems in place at RBHT to minimise the risk of a similar sequence of events happening here.

The concerns you have raised have been considered specifically by the inherited cardiac conditions care group, the
electrophysiology care group and the wider heart division and Trust and my responses are set out below.

1. The consultant responsible for Mr Chapman’s care in August and November 2015 was based at the time at
Barts NHS Trust and is now employed at the Brompton. The consultant was responsible for reviewing the
investigations that he (and other members of his team in their absence) had requested. There appeared to

be no check mechanisms in place to ensure that this was done and appropriate action taken in line with
the Guidelines,

ed
www. rbht.nhs.uk ee @RBandH

The RBHT Sudden Cardiac Death (SCD) Service is reviewing compliance with the European Society of
Cardiology (ESC) 2014 guidelines on diagnosis and management of hypertrophic cardiomyopathy. The RBHT
Cardiomyopathy service (which includes SCD patients) is consultant delivered with a specialist consultant
present in every clinic. Clinic letters have a standardised format including risk stratification for SCD risk
(calculated using the SCD calculator) which includes regular Holter rhythm monitoring as per the ESC 2014
guidelines, All Holter tapes are reported by trained cardiac physiology technicians and findings of concern
communicated directly to the referring consultant by phone or email (even if requested by a fellow). Holter
monitor reports are uploaded into the electronic patient record (EPR) along with all other investigation
results. Abnormal Holter results are regularly discussed at MDT meetings. MDT discussion is not a pre-
requisite for ICD implant at RBHT and urgent cases are referred directly to an implanting consultant who will
list the patient as appropriate. Where MDT discussion is required (complex patients or those not meeting all
criteria) this occurs within 2 weeks. The non-urgent waiting time for ICD implant from time of agreement to
implant Is of the order of 8-12 weeks. As a result of the PFD notice the inherited cardiac conditions care group
are developing a standard operating procedure for notification of potentially significant arrhythmias.

2. There was also a concern in respect of the Holter interpretations and the presence or otherwise of NSVT
on the traces. Barts NHS Trust have instigated a new intreduction and training regime for its specialist

clinical fellows in the interpretation of Holter readings.

At RBHT all Holter monitor traces are interpreted and reported by trained electrophysiology technicians.
Training for cardiomyopathy subspecialty fellows in Holter monitor interpretation is provided ot regular MDT
meetings and consultant supervised clinics, in addition to standard training for general cardiology trainees in
rhythm interpretation,

3. During the course of the inquest, the evidence revealed during his dealings with Bart’s NHS Trust and,
more specifically, the lead consultant's emails were passed by Mr Chapman to the consultants. It became
clear during the inquest that those emails were often not viewed and for acted upon and as a result no
response was received by the patlent, It Is fully appreciated that consultants are busy with their clinical
responsibilities covering wards, clinics and on-call. However, if contact details are provided for ‘direct
access’ to individual doctors/consultants It seems obligatory that those should be viewed, acknowledged

and patients responded to. Patient contact with medical professionals, not just hospital related, is an
important part of medical practice. While this is a huge task, it would seem possible to come up with
either national or local guidelines in respect of the use of all forms of communication between patients
and their clinician (covering phone and emails).

RBHT is in the process of exploring current practice in relation to email correspondence between clinicians and
patients and, pending production of any national guidelines from the Department of Health, will consider production
of local guidance to clinicians based on the NHS England Accessible information Standard ‘Using email and text
messaging far communicating with patients. guidance from the Information Governance team at NHS England’
(May 2016).

| hope you are reassured by my response to the concerns you have raised in relation to Mr Chapman's very sad
death, the circumstances of which have been discussed at length and the implications for the service at RBHT
acknowledged,

Yours faithfully

ee

Robert J. Bell
Chief Executive