Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0162, written 11 Mar 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Mar 2019 |
|---|---|
| Reference | 2019-0162 |
| Deceased | Peter Carroll |
| Coroner | Jean Harkin |
| Coroner area | Manchester City |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Manchester University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Sir Michael Deegan, Chief Executive of MFT Copied for interest to: Chief Coroner Next of kin 1 CORONER I am Ms Jean Harkin, Assistant Coroner, Manchester City Area 2 CORONER’S LEGAL POWERS I 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 INQUEST I concluded the inquest into the death of Peter CARROLL on 5th October 2018 and recorded that he/she died from: 1a Peritonitis b Perforated caecal volvulus; operated on c Perianal squamous cell carcinoma requiring colostomy II Coronary artery atheroma and pulmonary embolism and obesity 4 CIRCUMSTANCES OF THE DEATH The deceased had a complex medical history. He had a chronic ulcer on the need to craft for over 30 years and this developed into malignancy diagnosed in early 2017. A biopsy was taken on 6th October 2016. This was not recorded on the deceased discharge notification form and it was not until the 20th April 2017, at the result of squamous cell carcinoma, was it seen by the treating consultant. Although the delayed biopsy reporting did not contribute to this death, if such delay continues, It could result in future fatalities. An Incident Investigation Report Level 2 Comprehensive was compiled and the investigation reviewed the following: 1 1. The biopsy taken on 6th October 2016 was not recorded on the deceased’s discharge notes. Therefore, the treating consultant and administrative staff were unaware of the need to chase results or indeed the seriousness of the results. 2. The sample was wrongly labelled and as a result not reported to the multidisciplinary team warranting earlier action. Although certain measures have been implemented to try to prevent recurrence, I am not satisfied that this is sufficient. 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 MATTERS OF CONCERN are as follows: I am concerned that there is no leading physician signing off these reports in addition to processing by input on it systems thus reducing the effectiveness of the reporting. I am concerned that a 6 month delay in reporting, on the evidence, meant that a curable treatment was not an option however if reported in a timely manner, would most likely have resulted in a favourable outcome. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 7th May 2019. I, 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to Interested Persons. I have also sent it to organisations who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 2 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. 9 DATE: NAME OF CORONER: 11th March 2019 Signed: Ms Jean Harkin HM Assistant Coroner for Manchester City Area 3
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.
Joint Group Medical Directors’ Office Trust Headquarters Room 215, Cobbett House Oxford Road M13 9WL Tel: 0161 701 0205 Email: t 09 May 2019 Ms J Harkin HM Assistant Coroner HM Coroner’s Office – Manchester City Area Manchester City Coroners’ Office & Court Exchange Floor The Royal Exchange Building Cross Street Manchester M2 7EF Sent via email to: coroners.office@manchester.gov.uk Dear Ms Harkin Re: Mr Peter Carroll – Regulation 28: Prevention of Future Deaths Thank you for highlighting your concerns in respect of this case, which I have now had the opportunity to look into. The response required from Manchester University NHS Foundation Trust is in relation to the following: no leading physician signing off reports concerns re 6 month delay in reporting With regard to the responsible physicians signing off Histopathology reports; since this incident, processes in both Histopathology and the Department of Surgery have been strengthened. In the Department of Histopathology, measures have been instituted such that in the event of apparently unexpected or metastatic malignancy in a specimen from a site outside the pathologist’s area of expertise, that case is redirected to another pathologist who specialises in that field. All confirmed cancer cases are listed for discussion at relevant multidisciplinary team meetings (MDTs). In the case of delay or inability to discuss in the appropriate MDT, pathologists/pathology administrative staff have been instructed to email the report directly to the responsible clinician. In addition, a printed report marked ‘Urgent Report’ will be sent to the responsible clinician. The Royal College of Pathologists issued guidance in October 2017 in relation to the communication of critical and unexpected pathology results (Document G 158 – which is the Royal College of Pathology document number that describes the process when there is unexpected pathology – enclosed as attachment). MFT Pathology team have confirmed that the process for managing pathology results has been updated following this investigation and in line with the guidance that all histology samples confirming cancer diagnosis are directed to the appropriate cancer MDT. Within General Surgery, as part of the actions relating to this investigation, the team undertook a review of the administration processes in relation to histopathology paper results. The provision of paper results currently provides a backup assurance system to the electronic process. It was confirmed by the Administration Manager on 27 April 2017, that as part of this review into Mr Carroll’s case, all histology paper results are now date stamped upon arrival into the department and added to a tracker. An outcome form is then attached to the histology result that requires the requesting consultant to review, action and sign off with immediate effect and this is then updated on the tracker. The administration team monitor the tracker on a monthly basis to ensure the outcome is completed. A summary of the investigation and the learning was shared formally across the Division at the Surgery Clinical Effectiveness Group meeting on 20 April 2018 to ensure that all surgical teams had effective processes in place to deal with similar histopathology reports. The investigation also found that another factor in this incident was that the Discharge Notification Form (DNF) did not report that a biopsy had been taken. Whilst Mr Carroll’s operation note was available electronically to view on the theatre ORMIS electronic record system in October 2016, at that time it was necessary for clinicians to undertake a separate log- in to access operation notes when DNFs were being completed. This process has been strengthened from April 2017. MFT Chameleon Electronic Patient Record (EPR) system improvements have facilitated the inclusion of operation notes thus creating a single electronic record source to access operation notes when DNFs are being completed hence reducing the possibility of similar omissions, due to the need to refer to multiple sources of information. A further plan to improve communication of test results is currently being implemented at our Oxford Road site. At the Wythenshawe site of MFT, we introduced a fully electronic paperless system of reporting test results to requesting clinicians, which facilitates electronic results acknowledgement and allows tracking of clinician performance in reviewing results. We are currently introducing a similar system within the Chameleon EPR at Oxford Road site. The investigation outcome concluded that it was not possible to ascertain with any certainty whether the 6 month delay in reviewing Mr Carroll’s biopsy results impacted negatively upon his treatment plan, or indeed influenced his prognosis. However, we sincerely apologise to Mr Carroll’s family for this delay and any additional distress arising from it. Please accept my assurances that lessons have been learned from this case and appropriate actions have been put in place to address the issues raised. If you require anything further then please do not hesitate to contact me. Yours sincerely Joint Group Medical Director Encl. www.mft.nhs.uk Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services
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