Roger Ballard

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Tameside and Glossop 
Integrated Care 
NHS  Foundation Trust 

Chief Executive  Officer 
Silver Springs 
Fountain  Street 
Ashton-under-Lyne 
Lancashire 
OL69RW 

15 July 2021 

Ms Alison  Mutch OBE 
HM  Senior Coroner 
Manchester South Coroner's Court 
1 Mount Tabor Street 
Stockport 
SK1  3AG 

Dear Ms Mutch, 

Trust  Response  to  Prevention  of  Future  Deaths  Report  issued  following  the  Inquest 
touching upon the death of Mr Roger Ballard 

I am  writing  in  respect of your email  dated  24th  May 2021  by way of a  Regulation  28  Report 
issued following the Inquest touching upon the death of Mr Roger Ballard, which concluded on 
16th  April  2021.  I hope to  be  able  to  address the  concerns  raised  in  your report,  and  set out 
below my response in that respect. 

Concern 1 

The  Inquest heard evidence in  the  way that the  scan was reported and recorded was not clear 
and then contributed to the treating clinician not appreciating the  scan findings. 

When  an  investigation  is  undertaken  such  as  a  CT  scan,  it  is  expected  that  the  treating 
clinicians  should  be  logging  onto the  PACS  system  and  reviewing  the  scan  report  instead  of 
relying  on  what  has  been  transcribed  in  the  medical  records.  This  is  to  avoid  any 
misinterpretation  or the  omission  of  any  detail,  which  may  be  vital  when  making  a  clinical 
decision  about  a  patient's  management  plan  and  on-going  treatment.  This  expectation  is 
clearly  documented  in  the  Trust's  Radiology  Requesting  and  Reporting  Policy,  which  all 
clinicians are required to  be familiar with as part of their post at the Trust. 

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NHS  Foundation Trust 

As  determined  during  evidence  at  the  Inquest  of  Mr  Ballard,  the  treating  clinician  failed  to 
review the  CT scan  and  instead,  relied  on  what  had  been  documented  in  the  medical  notes 
alone, when making clinical decisions about Mr Ballard's care.  This clinician wishes to forward 
his  sincere  apologies  that  this  incident  occurred.  He  has  reflected  on  his  own  practice  and 
discussed  Mr Ballard's care  and  treatment with  his operational  line  manager and  also  with  a 
senior member of our clinical  leadership team. 

To reiterate the standards we expect of our clinicians,  Mr Ballard's story is being shared across 
the Trust by way of a 7 Minute Briefing (enclosed for your information). The learning from this 
story  has  been  put  on  the  agenda  for  the  Trust's  Grand  Round  meeting,  a  regular  forum 
attended  by  clinicians  of all  specialties  and  experience.  It  will  be  shared  by  Dr 
, 
Clinical Director for Urgent Care.  In addition to this,  Ms 
, Associate Medical Director, 
will  share  the  learning  from  this  case  at the  Clinical  Advisory Group,  which  includes  Clinical 
Directors and  Medical Leads from all areas of the Trust and which  is chaired  by me as Medical 
Director. To ensure that all learning has been identified in relation to this issue, an investigation 
has also been commissioned as part of our serious incident framework and the findings of this 
will be presented to our Executive Scrutiny Panel which  I and the Executive Director of Nursnig 
and  Integrated Governance attend. 

In addition,  I wish to give you wider assurances around  how imaging is  reported  and  reviewed 
by clinicians at the Trust. The Trust has been developing a Results Governance Tracker, which 
has already been  implemented  in  one major area of the Trust.  It is anticipated that this roll-out 
will continue,  although it did unfortunately experience some delays due to the pandemic. Once 
this Tracker is Trust-wide, it will ensure that all Pathology and Radiology results will have to be 
acknowledged  as  read  on the PACS  system within  a  specified  timeframe. This will  assist our 
clinicians  in  complying  with the  existing  expectations on  their practice  and  ensure  safer care 
for patients. 

Concern 2 

The  documentation regarding clinical decisions taken,  including the  decision not to  follow the 
advice of the  neurosurgeons was not documented in  the notes.  It was unclear if there  was an 
expectation that where clinicians took a decision contrary to such advice how and in what detail 
the  rationale should be recorded within the notes. 

It is an expected standard that any decisions made relating to a patient's care and management 
plan are to  be documented within the  medical  records.  This includes discussions with tertiary 
centre colleagues, the advice they provide, and any decisions made to deviate from this advice 
and the reasons why. As I am sure you are aware, this requirement is within the GMC standards 
and  guidance  relating  to  documentation,  and  is  absolutely expected  from  all  medical  staff.  In 
addition,  as  part  of junior doctor  induction,  clinicians  are  sign-posted  to  resources  to  assist 
them  in  managing their professional responsibilities  and obligations regarding  documentation 
in  medical records. 

The  clinician  involved  in  this  matter  has  reflected  on  this  point  and  learning  has  also  been 
included in the 7 Minute Briefing, shared across the Trust.  Further, a documentation standards 
audit has also been commenced  and dependent on the 

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Tameside and Glossop 
Integrated Care 
NHS  Foundation Trust 

outcome  and  results  of this  audit,  an  action  plan  will  be  developed  to  address  any  issues 
identified. 

I am pleased to advise you that our colleagues at Salford  Royal  Hospital (part of the  Northern 
Care  Alliance)  have  introduced  an  on-line  referral  process  from  17th  May  2021.  This  new 
system  requires that all  referrals to  the  Neurology Team at Salford  are completed on  a virtual 
platform. The advice provided will then  be  documented on this portal also.  The written advice 
is  available  for  the  referring  team,  who  are  then  expected  to  document  the  same  and  any 
decision and rationale to depart from this advice, if that is the decision they make regarding the 
patient's  management.  For  your  information,  I enclose  a  leaflet  produced  by  Salford  Royal, 
which details how referrals are to be made under the new online system. 

Finally,  I  wish  to  assure  you  that  outcomes  and  learning  from  incidents,  complaints  and 
Safeguarding investigations are progressed through the Integrated Governance work streams, 
through the Divisional Governance Forums, and  Clinical Leadership Forums. Where individual 
learning, or further measures are required, this will be undertaken within the existing Divisional 
mechanisms  and  HR processes.  As  the  Trust  has  commenced  an  internal  investigation  into 
the concerns you  have raised, this usual process will  be followed. 

I hope my response sufficiently addresses your concerns and assures you that they have been 
taken  seriously.  The  doctors  involved  in  Mr Ballard's  care  and  treatment  have  extensively 
reflected on their actions, to ensure a similar occurrence is avoided. 
I sincerely apologise to 
the family of Mr Ballard for the obvious distress the care provided to  him  has caused  them.  I 
accept and  acknowledge that the care fell  below the  standard  expected  and  will  be writing  to 
them separately to explain the steps taken and to offer my condolences again. 

Should you have an 
or clarification,  please do 

t hesitate to  contact me. 

ueries arising from the content of this letter or require further information 

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7 MINUTE  BRIEFING 

LEARNING  FROM  INQUESTS 

 2.  Concerns 

3.  The incident 

1: Background 

On  16 April 2021, the Trust participated in the 
inquest into the  death  of RB,  who  sadly  died 

at  home  on  30  September  2020,  after  care 
and  treatment at TGH. 

During 

the 

inquest, 

the  Coroner 

raised 

concern  with  evidence  that  she  heard  from 
Trust  witnesses  and  felt compelled to issue  a 
Prevention  of  Future  Deaths  Report  to  the 
Trust. 

The Coroner's concerns were two-fold: 

a)  The  way  in  which  the  CT  scan  was  reported  and  then 
recorded  was  not  clear  and  contributed  to  the  treating 
clinician  not appreciating the scan  findings,  and; 

b)  The  documentation  regarding  clinical  decisions  taken, 
including  the  decision  to  not  follow  the  advice  of  the 
neurosurgeons,  was  not  documented  in  the  notes.  It  was 
unclear  if there  was  an  expectation  that  where  clinicians 
took  a decision  contrary  to  such  advice,  how  and  in  what 
detail, the rationale should be  recorded within the notes. 

7.  Implementing change 

a)  Results Governance Tracker - The  roll-out of this Tool is ongoing across 
the Trust and  requires that all  Pathology and  Radiology results have to 
be  acknowledged as  read  on the PACS  system, within a specified 
timeframe. This will help ensure clinicians are  reviewing imaging 
reports and not relying on  medical records for full  details of patients. 

b)  Taking Responsibility- individual clinicians must take responsibility to 
ensure they are familiar with their duties regarding documentation. 

6.  Recommendations 

a)  Personal learning and reflection for those involved in the care. 

b)  Sharing  this  story with  Clinicians  at  all  levels  (Grand  Round  and 
CAG) to ensure they are reminded of the importance of reviewing 
imagining reports and of being familiar with Trust policies around 
head injury management and record keeping in patient notes. 

5.  Findings 

a)  The discharging clinician should have reviewed 
the CT scan  report prior to discharge to ensure 
he was fully aware of the findings when making 
clinical  decisions.  Had the clinician  been aware 
of  the  bleed,  he  would  have  stopped  the 
in  for  further 
anticoagulants  and  kept  RB 
observation. 

b)  The 

clinician 

discharging 

have 
documented the reason  behind the decision to 
the 
depart 
Tiertiary centre. 

from  Specialist  Advice 

should 

from 

RB  attended  ED  on  12/09/20 with  a suspected  head  injury.  He 

was  admitted 
to  AMU;  neurological  observations  were 
undertaken,  and  a  DNACPR  was  completed.  RB  was  on 
anticoagulants and therefore a CT head  was  performed,  and  his 
anticoagulants  were stopped.  CT  head  confirmed subarachnoid 
haemorrhage  and  contusions  to  the  left  side  of the  brain.  The 
findings were discussed with the Stroke Team and Mr Ballard was 
to  be  admitted  with  Beriplex.  Salford  Royal  advised  RB  was  for 
conservative  management  and  that  anticoagulants  should  be 
stopped.  As  his  family  wished  for  him  to  be  at  home,  he  was 
discharged,  with  an  outpatient's  CT  scan  in  2  weeks.  RB  was 
restarted  on  anticoagulants  on  discharge  due  to  the  risks 
associated with a PMH  of AF. 

RB  attended  ED  again  on  15/09/2020,  with  a suspected  stroke. 
Anticoagulants were discontinued and  ED  discussed with Salford 
Royal who confirmed that RB  was for no further intervention , On 
17/09/2020  RB  was  palliated  and  discharged  home.  Sadly,  he 
died at home on  30/09/20. 

4. The Review 

During  the  course  of the  inquest  hearing  it 
came to light that -

a)  The  decision 

to  discharge  RB  with 
anticoagulants  was  made  without  the 
knowledge of the bleed on  his  brain. This 
was  due  to the  discharging  clinician  not 
report 
having  reviewed  the  CT  scan 
(which  was  available  in  the  notes)  and 
instead,  relying  on  what  was  written  in 
the  notes  by  another  clinician,  that  RB 
had  a contusion . 

to 

discharge 

b)  The  discussion  and  reason  behind  the 
decision 
with 
anticoagulants  (due  to  the  high  risk  of 
from  Specialist 
stroke),  and  depart 
advice,  was  not  documented 
the 
medical  records. 

RB 

in 

 Ilia Patient Pass 

All  referrals should now be 
made via the Patient Pass 
referral system. 

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To  access the system, go to: 
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·  Roll  out due to commence 17th May 2021 

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