Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0135, written 24 Apr 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Apr 2021 |
|---|---|
| Reference | 2021-0135 |
| Deceased | Alfred Jones |
| Coroner | Alison Mutch |
| Coroner area | Greater Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside and Glossop Integrated Care NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: Greater Manchester Health & Social Care Partnership, and NHS England 1 CORONER I am Alison Mutch , Senior Coroner, for the Coroner Area of Greater Manchester South 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 INVESTIGATION and INQUEST On 7th September 2020 I commenced an investigation into the death of Alfred Jones. The investigation concluded on the 24th March 2021 and the conclusion was one of narrative: Died from a combination of Covid-19 and pneumonia contracted whilst an inpatient at Tameside General Hospital and exacerbated by the complications of an accidental fall at home and a further fall whilst an inpatient at Tameside General Hospital. The medical cause of death was 1a) Bronchopneumonia in combination with Covid-19; II) Falls with vertebral fractures, Type 2 diabetes mellitus, pulmonary fibrosis, heart failure and epilepsy. 4 CIRCUMSTANCES OF THE DEATH Alfred Jones had an accidental fall at home. He was admitted to Tameside General Hospital. He had a fracture at L3. He was in significant pain and had limited mobility. Whilst awaiting further investigation he had a fall on the ward resulting in fractures at L1 and L5. Whilst being medically optimised for discharge he tested positive for Covid-19 acquired in hospital. He was initially asymptomatic but began to deteriorate rapidly, on 6th September 2020. On 7th September 2020 he died at Tameside General Hospital. 5 CORONER’S CONCERNS 1 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. – 1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner. This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS. This was compounded by a shortage of radiology staff which the inquest was told is part of a wider issue of a national shortage of qualified radiologists and radiographers. This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 23rd June 2021. 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 the following Interested Persons namely may find it useful or of interest. (family of deceased), who I 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 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 24th April 2021 2 Signature: Alison Mutch, HM Senior Coroner, Manchester South 3
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.
Greater Manchester Health and Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN Date: 23 June 2021 Ms A Mutch OBE HM Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Dear Ms Mutch Re: Regulation 28 Report to Prevent Future Deaths – Alfred Jones 07/09/2020 Thank you for your Regulation 28 Report dated 30/04/2019 concerning the sad death of Alfred Jones on 07/09/2020. Firstly, I would like to express my deep condolences to Alfred Jones’s family. The inquest concluded that Alfred’s death was a result of 1a) Bronchopneumonia in combination with Covid-19; II) Falls with vertebral fractures, Type 2 diabetes mellitus, pulmonary fibrosis, heart failure and epilepsy. Following the inquest you raised concerns in your Regulation 28 Report to Greater Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future deaths will occur unless action is taken. This letter addresses the issues that fall within the remit of GMHSCP and how we can share the learning from this case. The Greater Manchester system is cognisant of the capacity issue in terms of slots for MRI scanners both in the Trust and the wider NHS. There is also the compounding issue of the shortage of radiology staff. This is an issue that is prevalent across the country as fundamentally there are insufficient numbers of qualified radiologists and radiographers. Tameside and Glossop Integrated Care NHS FT At the time of Mr Jones’ referral, Tameside and Glossop Integrated Care NHS Foundation Trust (T&GIC FT) was sourcing additional scanner capacity by provision of a mobile MRI scanner. This was implemented on 20th September 2020, offering additional outpatient scanning capacity for 12 hours per day, 7 days per week. The mobile MRI van is still used currently to provide additional capacity. It is also worth noting that the Trust did not reduce or delay suspected cancer patient scans due to the pandemic, and therefore, the MRI scanner was being fully utilised. In 2019, the division of clinical support services was established at T&GIC FT and encompasses diagnostics including Radiology. This was intended to provide coordinated leadership, oversight and governance. Since this time, investment has been made to increase the clinical workforce, increasing the number of substantive Radiologist from three to five with a further two undertaking their CESR qualification (Certificate of Eligibility for Specialist Registration), there are also 3 locum consultants bringing a total establishment to 8.5 whole time equivalent. This is an increase of 3.5 in the last 18 months. In addition to this there is also a Consultant Sonographer and 5 Advance Practice Reporting Radiographers. Regional Collaboration and infrastructure to address the shortfall A Greater Manchester Imaging Network has been established, and there are several examples of interventions taking place across GM to address the imaging workforce challenges. However, it has been agreed that a regional approach should be taken which has resulted in the three NW Imaging Networks working collaboratively to develop a NW Imaging Workforce Strategy (out for consultation until 12/6/21). Health Education England NW (HEE) has commissioned a programme of work to support and progress Diagnostic Radiographer (DRAD) workforce planning priorities across the region, through scoping activities and targeted actions/ interventions. This will ultimately provide a North West (NW) imaging workforce framework and strategy. Although the overall approach is regional, each ICS has its own workforce team that will be required to deliver on local workforce priorities. The NW Imaging Workforce Strategy The strategy focusses on the professions involved in delivering imaging services: • Radiologists • Diagnostic Radiographers and Sonographers • Assistant Practitioner Radiographers • Radiology Support Workers Following approval and subsequent adoption of the strategy, a workforce implementation plan for the North West will be developed. This will provide a framework for imaging networks to develop their own workforce plans by offering a range of initiatives/ solutions/ interventions that can be developed and implemented for the imaging workforce in Cheshire & Merseyside (C&M), Greater Manchester (GM) and Lancashire & South Cumbria (L&SC), neighbourhoods and the populations they serve. Greater Manchester Allied Health Professions Workforce Programme The GM Allied Health Professions workforce programme has several interventions that aim to increase the supply, bridge the gap between education and employment and enable the workforce to develop and grow. Therapeutic and diagnostic radiography are priority areas including the following interventions: into account taking the • Pre-registration education expansion • Placement expansion • Widening participation and workforce diversity • Careers activity • Return to Practice • AHP support workforce • Apprenticeships (level 2 – 6) • Reducing Pre-registration Attrition and Improving Retention (RePAIR), including preceptorship • Leadership • Better understand and utilise GM AHP workforce data • Support AHPs to actively engage in GM Cancer programme ❖ Advanced Clinical Practice and consultant roles Clinical Placement Expansion Programme The University of Salford is currently delivering a HEE funded project (Expansion of PreRegistration Placements for Diagnostic Radiography) to increase student numbers to support the workforce shortages in radiographers. Student numbers are projected to increase by 30 places over the 2019 baseline of 62 over a 3-year period. In addition to under-graduate increases in student numbers UoS is working in collaboration with the clinical collaboration lead for the Radiology Imaging Network to support workforce needs in the future with post-graduate offerings. Activity to promote Radiography as a career choice Throughout the year several activities take place where Allied Health Professions career are showcased and promoted to our communities in GM. We are committed to prioritising Diagnostic Radiography during career events in 21/22. Next steps The NW Imaging Workforce Strategy has been informed by engagement with the workforce groups from the three NW ICS, the NW DRAD WAG, HEE, various groups undertaking specific workforce projects and colleagues in other regions. To support delivery of the strategy, a NW implementation plan for the next 5 years will be developed, which will inform the local implementation plans for the three ICS. The implementation plan will describe the clear steps we will take to embed and progress the priority areas articulated here. It will importantly contain an approach to communication and support for ICS to enable each system to build and deliver on the areas of focus critical for their systems. Actions taken or being taken to prevent reoccurrence across Greater Manchester. 1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE. 2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice. I hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. Yours sincerely Chair of GM Medical Executive, GMHSCP
Ms Alison Mutch
HM Senior Coroner, Manchester South
Coroner's Court
1 Mount Tabor Street
Stockport
SK1 3AG
National
Medical Director
Skipton House
80
London Road
SE1 6LH
2nd July 2021
Dear Ms Mutch,
Re: Regulation 28 Report to Prevent Future Deaths – Alfred David Jones
Thank you for your Regulation 28 Report (hereafter “report”) dated 30 April 2021
concerning the death of Alfred David Jones on 7 September 2020. Firstly, I would
like to express my deep condolences to Mr Jones’s family.
The report concludes Mr Jones’s death was a result of bronchopneumonia in
combination with Covid-19 contributed to by falls with vertebral fractures, Type 2
diabetes mellitus, pulmonary fibrosis, heart failure and epilepsy.
Following the inquest you raised concerns in your report that there is a shortage of
MRI scanners both in the Trust and the wider NHS. This was compounded by a
shortage of radiology staff which the inquest was told is part of a wider issue of a
national shortage of qualified radiologists and radiographers. This led to a
prolonged admission in hospital whilst awaiting tests and led to him having a fall
whilst on the ward and contracting Covid-19 whilst an inpatient.
I am not aware of the precise details of the events prior to Mr Jones’s death,
although I can comment that generally, if access to MRI services is experiencing
challenges, alternate imaging such as CT scanning can often have an important
role in diagnosis and timely condition management. This is particularly applicable
for vertebral fractures and may have adequately answered the diagnostic question
more rapidly. This alternate imaging option is often required for patients who for
example suffer from claustrophobia or have cardiac pacemakers.
From a National perspective, in supporting the ambitions of the NHS Long Term
Plan, NHS England & Improvement (NHSE&I) commissioned an independent
review of diagnostic services. The recently published report (October 2020),
also
Diagnostics: Recovery and Renewal conducted by
took into account the impact of the Covid-19 pandemic. The recommendations have
been accepted by NHSE&I and work has already begun to address the
NHS England and NHS Improvement
recommendations made, which include an increase in both imaging equipment and
imaging workforce in England.
Funding within the 2021/22 spending review has been targeted to support
diagnostics via the development of community diagnostic hubs which will in turn
augment access for inpatient activity in acute hospital services through the
movement of elective activity to community settings. It is anticipated that MRI, CT
scanning, Ultrasound and X-ray services will be the core imaging offer for these
new centres and will represent new additional imaging capacity.
There is also a recommendation regarding a major expansion of the imaging
workforce which is now being developed in tandem with Health Education England
(HEE) to augment training numbers for radiographers and radiologists, deliver new
Imaging Training Academies and pump prime innovative technologies to deliver
more productive and safer imaging services.
The National Imaging Strategy published in November 2019 also sets out the case
for the development of Imaging Networks across England and work is now well
underway to establish these new operating models to support increased service
resilience, quality of care and improved patient access.
Through these measures NHSE&I are supporting the transformation of imaging
services for the longer term and in recognition of the vital role diagnostics has in
supporting clinical services for patients.
Thank you for bringing this important patient safety issue to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
NHS England and NHS Improvement
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