Peter Smith

INHS|

The Shrewsbury and
Telford Hospital

NHS Trust

Trust Headquarters
Royal Shrewsbury Hospital

Mr J P Ellery Mytton Oak Road
Senior Coroner for Shropshire, Telford and Wrekin Shrewsbury
The Shirehall Shropshire
Abbey Foregate SY3 8XQ
Shrewsbury

SY2 6ND

Date: 30th March 2020

Dear Mr Ellery
Regulation 28 Report — Peter Smith (deceased)
| write in response to the Regulation 28 Report issued on 5 February 2020. For ease of reference, |

will respond to the Coroner's concerns following the numbering pattern within the Regulation 28
Report.

1. There was a significant delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma which
contributed to his death on the 4 March 2019.

The Trust and the teams involved recognise the delays in this case and have reviewed their pathways
and processes. From November 2019, the Trust has updated their Standard Operating Procedure
(SOP) which provides advice on the referral of patients for surgical resection of proven or suspected
lung cancer to prevent delays. This covers the following areas: .

Stages of investigations in patients under consideration for surgery;

Basic physiological assessment in all patients under consideration for surgery;

Focused investigations for specific patient groups;

Criteria for urgent cardiology opinion;

Criteria for urgent vascular opinion;

Lung Cancer Nurse Specialist patient assessment for all patients under consideration for
surgery; and

e Single point of referral to thoracic surgeons.

This document is enclosed at Appendix 1 for ease of reference.

Please note that at present cancer and imaging pathways will be severely compromised because of
the impact that public health priorities, namely corona virus, is having on the Trust.

2. Time was of the essence, but tests, reports, appointments and discussions took place consecutively
to the extent that by the time a final date for surgery was fixed it was no longer possible.

3. Had tests been conducted expeditiously and concurrently with predictable tests organised _in
advance it is likely that the surgery would have been able to take place significantly earlier than it did.

Concerns 2 and 3 will both be addressed below.

From November 2019, the Trust has streamlined the diagnostic pathway (enclosed at Appendix 2) for
patients being investigated for potential lung cancer which involved collaboration with Clinical
Commissioning Group’s regarding ‘direct to CT’ pathways and to the urgent ‘hot-reporting’ of chest x-
rays where there is a suspicion of lung cancer.

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Improvement work has been undertaken and evaluated with regards to developing diagnostic
‘bundles’ of tests to streamline investigations and agree which investigations are appropriate for
specific patient groups, recognising that each investigation involves a potential delay, but that it is
important to ensure that a patient is risk assessed appropriately prior to listing for surgical intervention.

These improvements have been ratified through the Trust’s Governance processes and are approved
by NHS England.

There have been additional actions prior to receipt of the Regulation 28 Report. There are as follows:-

e The Trust has formally discussed the SOP (referred to within section 1) at the Lung Cancer
Multi-Disciplinary Team (MDT) bi-annual meeting in January 2020;

e This case was discussed at the Respiratory Governance Mortality and Morbidity Meeting on 11
July 2019 and the Unscheduled Care Group Mortality and Morbidity Meeting on 10 January
2020.

e Every chest x-ray with an abnormality which is concerning for a potential lung cancer is now
flagged up to the Lung Cancer Team on a daily basis. Although, in the case of Mr Smith, his
initial x-ray had been reported as normal as the changes were subtle.

e There is daily triage of CT scan results performed following receipt of an abnormal chest x-ray
where the potential for lung cancer has been raised by the reporting radiologist. It has been
established that had this been the case for Mr Smith, this may have reduced the timescale
between radiology reporting and receipt of that report by the requesting clinician by six days.
This would also trigger the Lung Cancer Team and alert the patient’s Consultant.

e The request of additional tests can result in further delays; the Trust's new protocol has
standardised the pre-operative assessment process to try and minimise clinically unnecessary
tests, recognising that each additional test builds in a potential time delay.

e Patient’s cases do not need to be discussed at an MDT meeting in order to facilitate the
requesting of a PET scan, but only following receipt of the PET CT result.

e There has been an increase in surgical clinical capacity, preventing delays for clinic
appointments.

4. Although separate Trusts they were effectively treating Mr Smith's adenocarcinoma as one.

The Lead Clinician for Lung Cancer, Lead Cancer Clinician, a Consultant Cardiologist and Consultant
Vascular Surgeon met with thoracic surgeons at the University Hospital of North Midlands (UHNIM), to
formally discuss pre-operative patient work up on 12 September 2019.

The Shrewsbury and Telford Hospital NHS Trust and. UHNM continue to maintain close links and
working closely together in the diagnosis and treatment of lung cancer patients. UHNM cardiothoracic
surgeons attend SaTH weekly to operate surgical outpatient clinics and to attend weekly MDT
meetings in person.

All improvements have also supported the Trust in quality improvement to work towards compliance
with the National Optimal Lung Cancer Pathway which is due to come into practice by April 2020.

| hope the above provides assurance that the Trust has taken action to implement the lessons learned
from this sad case. If you require any further explanation please do let me know.

Yours sincerely

Ay i

| I diss arnt
\Chief Executive

Proud ToCare @ Make it Happen & We Value Respect g@v Together We Achieve

INHS

University Hospitals
.of North Midlands

NHS Trust

Our Ref: —INQ/120/19

Your Ref: 8036
Executive Suite

Trust Headquarters

Royal Stoke

Date: 01 April 2020 Springfield
Newcastle Road

Stoke on Trent

Mr John Ellery, ST4 6QG

Senior Coroner,
The Shirehall, Tel: 01782 676612

Shrewsbury
SY2 6ND

Dear Mr Ellery

The late Peter Edward SMITH deceased

| write further to you email dated 5 February 2020 enclosing a regulation 28 report to prevent future
deaths. | am pleased to provide a response to your report addressing your concerns surrounding the
death of Peter Smith.

Recorded Circumstances of the Death

“On 29th September 2018 a chest x-ray indicated a potential left upper zone abnormality resulting in a CT
scan being performed on 22nd November 2018 and a PET scan on 27th December 2018. Subsequent
tests and investigations lead to a date for surgery on 26th February 2019. Time was of the essence but by
then surgery was no longer possible. The deceased relapsed on 20th February and died on the 4th March
2019.”

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:

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1. There was a significant delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma which
contributed to his death on the 4"" March 2019.

2. Time was of the essence, but tests, reports, appointments and discussions took place
consecutively to the extent that by the time a final date for surgery was fixed it was no longer
possible.

3. Had tests been conducted expeditiously and concurrently with predictable tests organised in
advance it is likely that the surgery would have been able to take place significantly earlier than it
did. ;

4. Although separate Trusts they were effectively treating Mr Smith’s adenocarcinoma as one.”

You reported this matter under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Action Taken

The University Hospitals of North Midlands NHS Trust [UHNM] has taken the issues highlighted ens
the inquest seriously and | am grateful to you for raising potential areas for improvement.

The thoracic surgery department at UHNM provides a surgical service to the Shrewsbury and Telford
Hospital NHS Trust [SaTH] for patients with intra-thoracic problems needing surgery, including lung
cancer.

With regard to the delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma SaTH has
produced, in conjunction with and agreed by the UHNM visiting cardiothoracic surgeons, the attached
Standard Operating Procedure [SOP] - “Referral for surgical resection of proven or suspected lung
cancer”. SaTH has implemented the SOP and will be responding to you separately.

| sincerely hope that this report provides you with assurance that UHNM [and SaTH] have taken the
matters arising from the inquest of the late Peter Smith seriously. The Trust strives to provide a high
standard of care to all patients and | am grateful to you for raising these matters on this occasion and for
the opportunity for us to review our processes.

| should like to extend my condolences to the family of Mr Smith and my sincere apologies that Mr Smith
didn’t receive the standard of care at the end of his life that he deserved.

Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly.

Yours sincerely

Abobo

TRACY BULLOCK
CHIEF EXECUTIVE

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