Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0116, written 21 Jan 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jan 2019 |
|---|---|
| Reference | 2019-0116 |
| Deceased | Alfred Howell |
| Coroner | John Hobson |
| Coroner area | West Yorkshire (East) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Mid Yorkshire Hospitals NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
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:
The Mid Yorkshire Hospitals NHS Trust
1 | CORONER
| am an Assistant Coroner, for the Coroner area of West Yorkshire (Eastern)
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.
3 | INVESTIGATION and INQUEST
On 12% June 2018 an investigation was commenced into the death of Mr Alfred Howell
{known as ‘Alf}, aged 73. The investigation concluded at the end of the Inquest on 21%
January 2019. The conclusion of the Inquest was that Mr Howell's cause of death was
by way of Disseminated lung adenocarcinoma.
The conclusion was that this was a natural cause of death.
4 | CIRCUMSTANCES OF THE DEATH
On 30! May 2018 Mr Alfred Howell, (known as ‘Alf’)} was admitted to Pinderfields
Hospital, Wakefield following respiratory investigation which indicated deterioration
including the presence of now bilateral pleural effusions and the slight collapse of both
lungs. Although he was stable on a review, on 1% June 2018 his condition then
deteriorated. A further large collapse to the left lung was identified and although Mr
Howell was treated accordingly he suffered a cardiac arrest and passed away on 5
June 2018, his death being confirmed at 0407 hours.
5 | 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 matter of concern is as follows:—
During investigations into Mr Howell's medical condition, CT scans were taken on a
number of occasions.
Specifically, he underwent a CT scan on 24 March 2018 which was reported on by the
radiology department on 7 April 2018. Upon review at an MDT on 17* April 2018, a
deterioration of the changes previously seen in both lungs was noted. An MDT plan was
then to perform an early follow up CT to assess whether the changes might improve
given that he had further antibiotic treatment for infection.
The repeat scan took place on 17" May 2018 and was reported by the outsource
company TMC on 29" May 2018. At that stage the scan was abnormal and significantly
deteriorated and was brought to the attention of the Consuitant in Respiratory and
General Medicine. There had been an increase in the areas of consolidation, an
increase in the size of now bilateral pleural effusions and both lungs had collapsed
slightly. The Consultant took immediate steps to facilitate Mr Howell’s admission to
hospital.
The Consultant who provided evidence at the Inquest commented that a period of 5
days from CT scan to reporting by radiology is the timescale target within the Trust.
The aforesaid scans took 14 days and 12 days to be reported on respectively. The latter
scan was brought to the Consultant's attention immediately.
Mr Howell continued under investigation for a diagnosis and was treated appropriately.
Whilst the evidence at the Inquest did not indicate any contribution by delays in the
scans to his death, | am concerned that upon the evidence given that the reporting of
scans fell outwith an aimed for timescale of 5 days and that this could impact the
treatment of others patients in the future. | am under a duty to report this matter upon
consideration of the evidence.
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe your
organisation has 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 21st May 2019. |, John Hobson, 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
| have sent a copy of my report to the Chief Coroner and to the family who were an
Interested Party at the Inquest.
lam 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.
ns
oe) a John Hobson
Assistant Coroner
So West Yorkshire (Eastern)
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.
yy The Mid Yorkshire Hospitals NHS Trust Your ref: 14342 Our ref: 001.1/KS/VJ Date: 20 May 2019 Mr J Hobson Assistant Coroner ____Medical Director West Yorkshire (Eastern) Trust Headquarters and Medical Education Centre Coroner's Office and Court dea 71 Northgate West Yorkshire Wakefield if WF1 4DG WF1 3BS P| Dear Mr Hobson RE: Inquest touching the death of Mr Alfred Howell Regulation 28 Report On behalf of the Trust, | am truly sorry that you identified areas of concern with regard to the timeliness of reporting in our radiology department. The Trust is committed to continuing to improve our services and the experience of patients. The matter of concern that you raise was “that upon the evidence given that the reporting of scéns fell outwith an aimed for timescale of 5 days and could impact the treatment of patients in the future”. Evidence at the inquest did not indicate that this had made any contribution to Mr Howell's death. Radiology reporting turnaround time has been under pressure for some time now due to rapidly rising demand and limitations of the available trained workforce nationally to deliver the reporting workload. A variety of strategies are in place locally and nationally to manage this pressure such as radiographer reporting and outsourcing to private companies. There are no national standards for radiology reporting turnaround times. The prioritisation of image acquisition and reporting has to be tailored for different pathways, for example whilst it may be acceptable that outpatient reports are not provided on the day of acquisition this is clearly not acceptable for emergency department patients. As there is no nationally mandated standard for the reporting turnaround of examinations at Mid Yorkshire NHS Hospitals we apply our own guidance on the expected reporting turnaround times of radiology examinations. Different priority is given to different examinations depending on the modality ( Xray, CT, MRI, Ultrasound), urgency of the request (as indicated by the referrer) and the referral source e.g. Emergency Department, Inpatient vs outpatient & GP referral. We are also asked to prioritise patients on fast track cancer pathways meaning Striving for excellence An Associated Teaching Trust patients not on these ‘pathways will wait. longer. Clinical teams. can contact the radiology department when, due to a deterioration in the clinical condition of a patient, a report becomes more urgent to have itexpedited.. ..° .. cht | oe The Regulation 28 report indicated an expected report turnaround of 5 days but this is an incorrect figure for the CT examinations requested. Both were requested as routine outpatient priority, to which we set a recommended reporting time of 10 days. Despite this it is acknowledged that, as in the case of Mr Howell, we do not meet this target for every patient. | have attached at appendix 1.the guidance for reporting turnaround times for the different types of examinations. 7 _ Reporting turnaround times are a key performance indicator for the radiology department. As such they are monitored internally by the radiology department, divisional management team and reported to the Trust Board. As.an organisation we Strive to deliver the highest quality healthcare so this focus helps us to reduce the numbers of patients who wait longer than the internal target for an examination report. Given the complexity of the workload and the challenges meeting the reporting turnaround we have a risk management approach to the outstanding reporting. Unreported examinations wait within. a prioritised queue with resource prioritised to the strategic objectives of the organisation focussing on acute/clinically urgent and cancer pathways. The routine outpatient work load waits longer to be reported. This clinical stratification of the queue supports the risk management of any reporting backlogs. The increasing focus on the need to ensure that the reporting turnaround times are not too long has gained traction nationally culminating in a recent CQC report! undertaken into the situation. The recommendations of the report are that: 1.. NHS trust boards Should ensure that: 5 1.1. they have effective oversight of any backlog of radiology reports 1.2. risks to patients are fully assessed and managed 1.3, staffing and other resources are used effectively to ensure examinations are reported in an appropriate timeframe. 2. The National Imaging Optimisation Delivery Board should advise on national Standards for report turnaround times, so that trusts can monitor and benchmark their performance. —_ os 3. The Royal College of Radiologists and the Society and College of Radiographers should make sure that clear frameworks are developed to support trusts in managing turnaround times safely. Until any national standards are published by the National Imaging Optimisation Delivery Board or a clear framework is published by the RCR or SOR the radiology department will continue to work to its current standards. These will be reviewed in light of any national publications. * https://www.cac.org.uk sites/default/files/20180718-radiology-reporting-review-re ort-final-for-web.pdf | hope this provides clarity on the current situation with regards to radiology reporting turnaround at Mid Yorkshire Hospitals as well as the national context. It also outlines our approach to managing performance and the risk. If you require any further information please do not hesitate to contact me. Yours sincerely GMC No: 3455847, Medical Director Enc. Appendices 1
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