Deborah Hopkinson

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Saving lives, INHS|

Improving lives Northern Care Alliance
a ae laa : NHS Group

Salford | Oldham | Bury | Rochdale | North Manchester

Ref: CB HMC3395 Chief Medical Officer/Deputy Chief Executive
. Group Headquarters
2 3° Floor
Date: 2 July 2019 ‘ Mayo Building
Stott Lane
Salford
M6 8HD
Telephone: 0161 206 4657
Mr Cox
HM Assistant Coroner
Office of HM Coroner

The Phoenix Centre

L/Cpl Stephen Shaw MC Way
Heywood ,

OL10 1LR-

Dear Mr€ox My (OR
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Re: Mrs Deborah Anne Hopkinson ;

| am writing to you, in response to your Regulation 28 report dated 24 April 2019 regarding the
death of Mrs Deborah Anne Hopkinson who sadly died following an admission at Fairfield General
Hospital. At the outset, | should be grateful if you would pass on my sincere condolences to the
family of Mrs Hopkinson, | was sorry to hear that they have been given cause for concern at such a
difficult time. :

Thank you for bringing the concerns raised in the Regulation 28 report to our attention. The Trust is
dedicated to ensuring patient safety is maintained throughout all services. | would like to take this
opportunity to provide assurance to both you and the family that the Trust takes the concerns raised
very seriously and has conducted a thorough review.

Your concerns were as follows:

1. Equipment failures which were likely to have had some impact on Mrs Hopkinson’s
admission, namely:

a. When Mrs Hopkinson was re-admitted to hospital on 12 September 2018 there was a
delay of six days in involving the endocrine consultant at Fairfield Hospital due to the
computer system being down;

b. The analyser for running cortisol samples was down multiple times during Mrs
Hopkinson’s admission;

c. There was a significant deterioration in Mrs Hopkinson’s condition during the evening
of 25 September 2018 but a CT abdomen could not be performed due to the CT
scanner at Fairfield General Hospital not working;

d. When Mrs Hopkinson’s case was discussed at an MDT meeting on 13 September
2018 the MRI scan could not be viewed on the PACS system.

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Saving lives, INHS

Improving lives Northern Care Alliance
Le NHS Group

Salford | Oldham | Bury | Rochdale | North’ Manchester

2. While it was not possible to say on balance that these altered the outcome, there were
delays in obtaining advice from a specialist centre such as Salford Royal Hospital or the
Christie Hospital as follows:

a. Delay in referral to Salford Royal Hospital between 21 and 28 August 2018 following
an MRI scan which revealed pituitary adenoma;
b. Delay in seeking advice from specialists between 12 and 17 September 2018 and an
accepted delay in treatment for probable pneumocystis pneumonia.
In order to address each concern | have answered them as they have been written in your letter.

Equipment failures

e IT systems i
The Trust acknowledged and apologies that there was a delay nO being made aware of
Mrs Hopkinson’s readmission on 12 September 2018 and that the multi-disciplinary team (MDT)
was not able to view the MRI scan when it met on 13 September 2018 due to a Trust-wide failure of
the IT systems during this time.

There has been a subsequent Root Cause Analysis investigation into the incident and the source of
the problem was identified as a combination of equipment failure, required software reconfiguration
and’a broadcast storm.

The risk of recurrence of these issues has been addressed by replacement of the IT equipment,
completion of the software reconfiguration and installation of filtering equipment.

e Cortisol analysers
The Trust acknowledges that there were difficulties with the cortisol analysers during Mrs

Hopkinson’s admission and | refer tof) Consultant Haematologist’s statement in order to
offer assurance that the Trust has learnt from this.

As a result of the concerns, cortisol analysis was added to the test repertoire at Fairfield General
Hospital on 7 January 2019 and to two further analysers at North Manchester General Hospital on 7
February 2019.

This will reduce the turn-around time for results by removing the transport time, as well as
increasing resilience. The Trust expects that samples that need urgent processing would indicate
that the results were needed urgently and if urgent samples are not able to be processed locally, the
team will continue to transport them to other sites as has occurred in previous cases.

e CT scanner
The Trust apologises that the CT scanner at Fairfield General Hospital was not working on 25

September 2018.

There are continuity plans in place for all CT scanner downtime and a comprehensive contingency
plan, which was re-circulated to staff on 26 September 2018 in order to manage the downtime at
Fairfield General Hospital. Sadly, Mrs Hopkinson was not well enough to travel to North Manchester
General Hospital for a CT scan on 25 or 26 September 2018.

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Saving lives,

improving lives Northern Care Alliance
een aaa NHS Group

Salford | Oldham | Bury | Rochdale | North Manchester

In order to improve patient safety, the CT scanner at Fairfield General Hospital has been replaced. .
During the replacement works, a temporary mobile scanner was on site and in future it will also be
possible to bring in a mobile scanner in case of downtime or in the event that additional capacity is
required.

e Referral to Salford
The concern in relation to a delayed referral to the specialists at Salford Royal Hospital was not
raised at the hearing itself, nor in the conclusion and | have therefore sought additional input from
who was the treating consultant at the time in.order to provide assurance around this
point. ; é

The MRI scan reported on 21 August 2018 showed pituitary adenoma. BS «plains to me
that as 10% of the population have a pituitary adenoma that is often non-functioning, it is important
to confirm a diagnosis of Cushing’s disease biochemically in order to avoid unnecessary surgery to
a patient. For this reason, a 48 hour dexamethasone suppression test was needed along with
testing of ACTH levels and this was completed between 22 and 24 August 2018. The results were
reviewed by the Registrar on 28 August 2018 and discussed with Salford on the same day, with a
referral to MDT and neurosurgeons following this. Cortisol lowering medication was also started the
, same day.

Involvement of the Christie & treatment for PJP

It is accépted that there was a delay in ER becoming involved and seeking further advice
from specialists when Mrs Hopkinson was re-admitted on 12 September 2018, due to the IT system
downtime as addressed above and the Trust wishes to sincerely apologise to Mrs Hopkinson’s
family for this.

In addition to resolving the IT issues that led to the delay inf being: notified of Mrs
Hopkinson’s readmission, the Trust has issued a patient care alert to all staff across the Northern
Care Alliance Group. The alert raised awareness that this rare disease (Cushing’s Disease)
increased the risk of pneumocystis pneumonia and highlighted that this should be taken into
account when managing patients with Cushing’s disease.

To further disseminate the learning from this investigation this case was discussed in Morbidity &
Mortality meetings held by both the medical and ICU teams. In addition, the case was discussed in
detail at a Clinical Governance meeting on 19 March 2019, when the patient safety alert and
learning from the RCA was covered again.

These discussions covered the risk of pneumocystis pneumonia in Cushing’s Disease and that this
should be considered based on initial radiology. If in doubt, the team should request a sputum
sample to assess for pneumocystis pneumonia and consider prescribing septrin for this.

Awareness of Cushing's Disease is also included in the annual training for Core Medical Trainees.
Dr Smithurst will ensure that the consultant delivering this training is aware of this case and ensure
that all trainees are aware that due to the immunosuppression that occurs in Cushing’s disease and
Cushing's syndrome, patients are at risk of atypical infections, including pneumocystis pneumonia.

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Saving lives, NHS}

Improving lives Northern Care Alliance
eae ote NHS Group

Salford | Oldham | Bury | Rochdale | North Manchester

Trainees will also be reminded of the need to refer to the endocrine team urgently if they suspect
Cushing's, or if they are dealing with a patient already diagnosed with the condition. Consideration
will be given to using this case as a specific case study to further future learning.

HE i! also discuss this case at the local endocrine MDT and send a synopsis of the case
to her colleagues in advance of this, to aid discussion. [I will also feed this case back to
the Salford Royal MDT meeting in order to further disseminate learning:

Ido hope that this response provides assurance to you and Mrs Hopkinson’s family that Northern
Care Alliance has worked hard and continues to focus on ensuring that lessons have been learned
and improvements have been made.

| would like to conclude by apologising to Mrs Hopkinson’s family for the issues in her care that
have been highlighted above and assure the family that lessons have been learnt.

Please do not hesitate to contact me if you require any further information in relation to our
response. :

Yours sincerely

f ae
Consultant Emergency Medicine
Executive Medical Director, Salford Royal NHS Foundation Trust

Chief Medical Officer and Deputy Chief Executive Northern Care Alliance
(Incorporating Salford Royal NHS Foundation Trust and Pennine Acute NHS Trust)