Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0028, written 3 Feb 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Feb 2021 |
|---|---|
| Reference | 2021-0028 |
| Deceased | Monica McCormick |
| Coroner | Matthew Cox |
| Coroner area | Manchester North |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive, The Northern Care Alliance NHS Trust CORONER lam Mr. Matthew Cox, Assistant Coroner for the Coroner area of Manchester North CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 INVESTIGATION and INQUEST On 27 January 2021 I concluded the Inquest into the death of Mrs. Monica McCormick who died on 24 May 2020 at her home address. | reached the following conclusion in respect of Mrs. McCormick's death : Natural Causes to which neglect contributed CIRCUMSTANCES OF DEATH The deceased who was then aged 79 years but had no known significant previous medical history developed stomach pain at the beginning of October 2019 leading to a CT scan at Fairfield General Hospital on 6 October 2019 which revealed a colonic perforation with a differential diagnoses between focal diverticulitis and perforated proximal neoplasm. She was transferred to North Manchester General Hospital where she underwent an emergency laparotomy, sigmoid colectomy and end colostomy on 8 October 2019. The report on the pathology specimen taken at the time of the operation was dated 15 October 2019. This showed moderately differentiated adenocarcinoma with extramural, vascular lymphatic and peri-neural invasion. The pathology report was not communicated to the deceased although she remained an inpatient at North Manchester General Hospital until 16 October 2019. The diagnosis was not reported to her general practitioner at the time she was discharged. Scheduled outpatient appointments on 11 December 2019, 6 January 2020, 17 February 2020 and 9 March 2020 were all cancelled by the hospital. On 6 April 2020, a Colorectal Consultant at North Manchester General Hospital noted the results of the pathology specimen removed in October 2019 and it was only then that the deceased and her general practitioner were informed of the diagnosis. A subsequent CT scan identified that the cancer had spread into the liver and abdominal cavity. The deceased’s condition deteriorated and she died at her home address on 24 May 2020. Had appropriate consideration been given to the pathology report in October 2019 the deceased would have been referred for adjuvant chemotherapy at a time when she was still feeling well and such treatment would on the balance of probabilities have prolonged her life. 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:- Evidence was heard that the pathology sample was not followed up because despite labelling the specimen to include the word malignancy the operating clinicians did not complete an online “suspected cancer upgrade form” at the time of surgery. However there were also many opportunities to identify and rectify the initial error which were also missed: 1. Appropriate consideration was not given to the deceased’s medical records at the time of her discharge from hospital. 2. The pathology report was not communicated to her general practitioner at the time she was discharged from hospital. 3. Appropriate consideration was not given to her records at the time that each outpatient appointment was cancelled As a consequence of the initial error and the missed opportunities the deceased was not referred for adjuvant chemotherapy until shortly before her death. Evidence was heard that an earlier referral would have prolonged her life. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively 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 31 March 2021 . |, 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 following Interested Persons namely:- The legal representatives for Mrs. McCormick’s family. The Care Quality Commission 1 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 from. 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. Date: 3 February 2021 Signed: wt: “x
2 responses 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.
If calling please ask for: Jonathan Moise
Direct line / Ext: 0161
Email: jonathan.moise@pat.nhs.uk
Reference: HMC4207
26 March 2021
Dear Mr Cox,
Medical Director’s Office
The Royal Oldham Hospital
Rochdale Road
Oldham
OL1 2JH
I write to you following the inquest of Mrs Monica McCormick which concluded on 27 January 2021.
Following the inquest the Northern Care Alliance was issued with a Prevention of Future Death
notification with a requirement to respond by 31 March 2021 including details of actions proposed or
taken. At the outset please accept my sincere condolences to the family of Mrs McCormick.
Thank you for bringing your concerns to our attention. The Trust is dedicated to ensuring that
patient safety is maintained throughout all services. I 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
have conducted a thorough review of this case, both before and after the inquest.
Response to the matters of concern has been led by the Divisional Clinical Director - Surgery, Dr
Nick Tierney and can be found below.
Matters of Concern:
1. Appropriate consideration was not given to the deceased’s medical records at the
time of her discharge from hospital.
Our investigation confirms that the pathology results confirming the positive cancer diagnosis
were recorded on the pathology database on 15 October 2019, one day before discharge
from hospital.
Dr Nick Tierney has discussed this case with Mr Zahirul Huq, Clinical Director of General
and Colorectal Surgery, who has confirmed that it is unusual for a histopathology diagnosis
to be available at the time of discharge and that therefore this will have been the expectation
of the team caring for the patient.
We apologise that the team did not check whether there had been a histopathology
diagnosis at the time of discharge. We will share this PFD response at the Divisional of
Surgery Governance Meeting and discuss with team members the importance of checking
medical records in full when completing the Handover of Care Communication. It is
important to highlight that these documents are completed throughout the patient admission
to ensure a timely discharge once the patient is considered medically fit or optimised. We
would also like to give assurance that the actions agreed in this letter described under the
second matter of concern will ensure that any diagnosis of cancer will be communicated to
the patient in a timely manner and have appropriate oversight by the cancer services team.
2. The pathology report was not communicated to her general practitioner at the time
she was discharged from hospital.
Dr Tierney has reviewed the case and confirms that the pathology report was not
communicated to Mrs McCormick’s general practitioner (GP) at the time of discharge from
hospital. However disclosure to GP at this time would not be standard practice. Any letter
sent to the GP is also copied to the patient; this therefore would create the risk of a patient
being made aware of a cancer diagnosis without appropriate support in place on receipt of
the information.
It is best practice that when a cancer diagnosis is shared that this is undertaken in an out-
patient environment to the patient and next-of-kin, by the responsible consultant supported
by a cancer nurse specialist. The role of the cancer nurse specialist includes a holistic
approach to supporting the patient.
However, Dr Tierney does recognise that in the case of Mrs McCormick the delay in
informing the patient of the diagnosis led to an avoidable shortening of her life. On review of
the case it is recognised that the patient’s cancer was not upgraded onto the cancer pathway
because the pathology specimen had arisen from Mrs McCormick’s treatment and was a
new and unsuspected cancer rather than as a consequence of a diagnostic investigation
such as a biopsy. Upgrade onto the cancer pathway ensures that the patient is tracked on
the cancer tracking database (Somerset) so that the cancer services team can track the
appropriate and timely management of cancer treatment. We can confirm that following this
incident cancer services have developed a standard operating procedure for New
Unsuspected Cancer pathology, so that irrespective of whether cancers are found as a
consequence of treatment or investigation the patient will be added to the cancer tracking
database. By adding Mrs McCormick to the database the cancellation of outpatient
appointments would have been visible and appropriate resolution sought regarding the
disclosure and management of the cancer. This provides the ‘safety net’ required to ensure
that such a situation will not happen again in the future.
3. Appropriate consideration was not given to her records at the time that each
outpatient appointment was cancelled.
As per the concise investigation presented at inquest, Mrs McCormick was unfortunately
cancelled from outpatient appointment five times by the service and once by the patient. As
an organisation we recognise that this is not the service that we aspire to offer and for that I
apologise. It was the continued cancellation of outpatient appointments that led to the delay
in informing the patient of the diagnosis and progression of treatment. As per our response
to the second matter of concern, we can confirm that cancers identified via treatment, such
as Mrs McCormick’s, are now added to the cancer tracking database. This means that
cancellation of outpatient appointments would only be made taking into account the patient’s
cancer diagnosis. Dr Nick Tierney has also discussed outpatient appointment cancellations
with the Directorate Manager for General Surgery, who has agreed the following actions to
be completed by 31st March 2021, to support the reduction of cancellation of outpatient clinic
appointments:
• Review of management of leave by clinical staff to ensure due process in terms of
adequate notice (8 weeks as per policy).
• Review of the process for clinical and administrative oversight of outpatient
cancellations within surgery. This will identify any further improvements to be made.
• Update of the risk assessment related to surgical outpatient waiting lists, including a
review of controls in place, and any actions identified.
It is important to recognise the current challenge that the hospital faces with regard to waiting list
management. The impact of COVID19 on already busy waiting lists has been significant and as an
organisation we are unable to prevent the risk of outpatient cancellations fully in the future. We do
however continue to take learning from incidents such as this one seriously. By introducing the use
of cancer tracking for patients such as Mrs McCormick we feel assured that patients, who have a
cancer diagnosis identified outside of a diagnostic pathway, will not be cancelled from outpatient
waiting lists without clear recognition of the patient’s diagnosis and impact upon treatment.
I hope that this response has provided you with assurance that we have taken on board the
concerns identified during the inquest of Mrs McCormick. If you have any further questions please
do not hesitate to contact me.
Yours Sincerely,
Dr Jonathan Moise
Medical Director
Oldham Care Organisation
Medical Director’s Office The Royal Oldham Hospital Rochdale Road Oldham OL1 2JH Reference: HMC4207 26 March 2021 Dear Mr Cox, I write to you following the inquest of Mrs Monica McCormick which concluded on 27 January 2021. Following the inquest the Northern Care Alliance was issued with a Prevention of Future Death notification with a requirement to respond by 31 March 2021 including details of actions proposed or taken. At the outset please accept my sincere condolences to the family of Mrs McCormick. Thank you for bringing your concerns to our attention. The Trust is dedicated to ensuring that patient safety is maintained throughout all services. I 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 have conducted a thorough review of this case, both before and after the inquest. Response to the matters of concern has been led by the Divisional Clinical Director - Surgery, Dr and can be found below. Matters of Concern: 1. Appropriate consideration was not given to the deceased’s medical records at the time of her discharge from hospital. Our investigation confirms that the pathology results confirming the positive cancer diagnosis were recorded on the pathology database on 15 October 2019, one day before discharge from hospital. has discussed this case with , Clinical Director of General and Colorectal Surgery, who has confirmed that it is unusual for a histopathology diagnosis to be available at the time of discharge and that therefore this will have been the expectation of the team caring for the patient. We apologise that the team did not check whether there had been a histopathology diagnosis at the time of discharge. We will share this PFD response at the Divisional of Surgery Governance Meeting and discuss with team members the importance of checking medical records in full when completing the Handover of Care Communication. It is important to highlight that these documents are completed throughout the patient admission to ensure a timely discharge once the patient is considered medically fit or optimised. We would also like to give assurance that the actions agreed in this letter described under the second matter of concern will ensure that any diagnosis of cancer will be communicated to the patient in a timely manner and have appropriate oversight by the cancer services team. 2. The pathology report was not communicated to her general practitioner at the time she was discharged from hospital. has reviewed the case and confirms that the pathology report was not communicated to Mrs McCormick’s general practitioner (GP) at the time of discharge from hospital. However disclosure to GP at this time would not be standard practice. Any letter sent to the GP is also copied to the patient; this therefore would create the risk of a patient being made aware of a cancer diagnosis without appropriate support in place on receipt of the information. It is best practice that when a cancer diagnosis is shared that this is undertaken in an out- patient environment to the patient and next-of-kin, by the responsible consultant supported by a cancer nurse specialist. The role of the cancer nurse specialist includes a holistic approach to supporting the patient. does recognise that in the case of Mrs McCormick the delay in However, informing the patient of the diagnosis led to an avoidable shortening of her life. On review of the case it is recognised that the patient’s cancer was not upgraded onto the cancer pathway because the pathology specimen had arisen from Mrs McCormick’s treatment and was a new and unsuspected cancer rather than as a consequence of a diagnostic investigation such as a biopsy. Upgrade onto the cancer pathway ensures that the patient is tracked on the cancer tracking database (Somerset) so that the cancer services team can track the appropriate and timely management of cancer treatment. We can confirm that following this incident cancer services have developed a standard operating procedure for New Unsuspected Cancer pathology, so that irrespective of whether cancers are found as a consequence of treatment or investigation the patient will be added to the cancer tracking database. By adding Mrs McCormick to the database the cancellation of outpatient appointments would have been visible and appropriate resolution sought regarding the disclosure and management of the cancer. This provides the ‘safety net’ required to ensure that such a situation will not happen again in the future. 3. Appropriate consideration was not given to her records at the time that each outpatient appointment was cancelled. As per the concise investigation presented at inquest, Mrs McCormick was unfortunately cancelled from outpatient appointment five times by the service and once by the patient. As an organisation we recognise that this is not the service that we aspire to offer and for that I apologise. It was the continued cancellation of outpatient appointments that led to the delay in informing the patient of the diagnosis and progression of treatment. As per our response to the second matter of concern, we can confirm that cancers identified via treatment, such as Mrs McCormick’s, are now added to the cancer tracking database. This means that cancellation of outpatient appointments would only be made taking into account the patient’s cancer diagnosis. has also discussed outpatient appointment cancellations with the Directorate Manager for General Surgery, who has agreed the following actions to be completed by 31st March 2021, to support the reduction of cancellation of outpatient clinic appointments: • Review of management of leave by clinical staff to ensure due process in terms of adequate notice (8 weeks as per policy). • Review of the process for clinical and administrative oversight of outpatient cancellations within surgery. This will identify any further improvements to be made. • Update of the risk assessment related to surgical outpatient waiting lists, including a review of controls in place, and any actions identified. It is important to recognise the current challenge that the hospital faces with regard to waiting list management. The impact of COVID19 on already busy waiting lists has been significant and as an organisation we are unable to prevent the risk of outpatient cancellations fully in the future. We do however continue to take learning from incidents such as this one seriously. By introducing the use of cancer tracking for patients such as Mrs McCormick we feel assured that patients, who have a cancer diagnosis identified outside of a diagnostic pathway, will not be cancelled from outpatient waiting lists without clear recognition of the patient’s diagnosis and impact upon treatment. I hope that this response has provided you with assurance that we have taken on board the concerns identified during the inquest of Mrs McCormick. If you have any further questions please do not hesitate to contact me. Yours Sincerely, Medical Director Oldham Care Organisation
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