Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0040, written 3 Feb 2022. 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 2022 |
|---|---|
| Reference | 2022-0040 |
| Deceased | Mark Jones |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Other related deaths |
| 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: Secretary of State for Health & Social Care 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 16th November 2020 I commenced an investigation into the death of Mark Jones. The investigation concluded on the 22nd December 2021 and the conclusion was one of Narrative: Died from the complications of necessary surgery. The medical cause of death was 1a Haemorrhage from tongue following surgery for squamous cell carcinoma 4 CIRCUMSTANCES OF THE DEATH Mark Deardon Jones was diagnosed with squamous cell carcinoma of the tongue. He underwent complex surgery to treat his cancer including a left hemiglossectomy of the tongue. He was discharged home on 12th November 2020. On 13th November 2020 he had a catastrophic haemorrhage at the site of the hemiglossectomy and died at his home address 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. – 1 1. During the inquest the Court was told that there is a backlog in standard referrals such as Mr Jones being seen. This means that a referral which pre Covid meant a waiting time of approximately 2.5 months for an outpatient appointment now involves a waiting time of approximately 8 months. 2. Mr Jones’ referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol in place between dentists and secondary care to provide for the routine provision of photographs to assist in triage. Such a protocol to ensure the provision of photographs by referring dentists in conjunction with more consistent provision of information would, the inquest was told, be helpful in improving the quality of triage and reduce the risk of patients needing urgent care being missed. 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 31st March 2022. 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 the family, and Manchester Foundation Trust who may find it useful or of interest. 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 2 the release or the publication of your response by the Chief Coroner. 9 Date 3rd February 2022 Ms Alison Mutch HM Senior Coroner Manchester South 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.
From Helen Whately MP Minister of State for Social Care 39 Victoria Street London 16 November 2022 Alison Mutch HM Senior Coroner Manchester South Coroner’s Court Stockport SK1 3AG Dear Ms Mutch, Thank you for your letter of 9 February 2022 about the death of Mark Jones. I am replying as Minister of State for Social Care, and I thank you for the additional time allowed. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Jones’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. In preparing this response, Departmental officials have made enquiries with NHS England, as well as the relevant regulator in this case, the Care Quality Commission. There are three main issues in your report to respond to from a national perspective. You may wish to know that the guidance on the referral of patients with suspected cancer from dental services into secondary care services is included in the National Institute for Health and Care Excellence guideline (NG12) Suspected cancer: recognition and referral1. Section 1.8 makes it clear that, where the symptoms described in the oral cavity are observed, dentists should consider referring a patient through an urgent referral, which would normally mean that the patient is seen within two weeks. This advice is reinforced in the guidance to NHS commissioners on Commissioning Oral Surgery and Oral Medicine2. This document describes the services that should be provided, along with minimum standard specification for the commissioning of these services. It states on page 20 that: “if an oral cancer is suspected or there is a suspicious head and neck (includes salivary gland) mass etc., the patient should be referred as per (2 week) Cancer Referral Pathway wait criteria to a head and neck oncology service.” The Chief Dental Officer (CDO) has regularly emphasised the importance of this guidance. By way of example, the May 2021 Dental Bulletin3 focused on mouth cancer and included a leaflet on mouth cancer awareness for dental teams. Secondly, the expected referral route into Head and Neck Teams for dentists is via one of two NHS commissioned e-referral systems for dental practitioners. Both NHS online e-referral 1 https://www.nice.org.uk/guidance/ng12 2 https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/09/guid-comms-oral.pdf 3 http://createsend.com/t/d-50A7FF9BB4BF31622540EF23F30FEDED portal systems contain information regarding oral cancer and suspected lesions, and the necessity to follow the urgent referral pathway, with further guidance on minimum data set and imaging. The FDS system is used in the Manchester area and includes the ability to draw the lesion relative to key head and neck landmarks to assist the triage judgments of the urgency and appropriate receiving service of in the absence of a photograph4. The online portals specification and data/imaging requirements are based on the National Guidance5 to NHS Commissioners on Commissioning Oral Surgery and Oral Medicine and reflects the requirement, and the important point that you raised, about images to accompany a referral by dentists into secondary care. The Patient Journey set out on page 55 of the National Guidance makes it clear that: “Appropriate clinical images and radiographs to support diagnosis; ideally these should be in digital format.” This requirement is reinforced in many areas though local guidance or local referral practice issued by local commissioners to their system6. The content of an effective referral is also reinforced in professional guidance published by the College of General Dentistry (formerly the Faculty of General Dental Practice (UK))7. Section 2.3 on Making and Receiving Referrals (page 10) again makes it clear that referrals should be accompanied by appropriate images. In the light of your recommendation, the Chief Dental Officer (CDO) will again reinforce the importance of good referral practice in future communications on oral cancer to the dental profession and commissioners. In addition, she has recommended that the NHS cascades similar communication and guidance to NHS general medical practitioners who account for the vast majority of cases referred to Head and Neck centres. I hope this response is helpful. Thank you for bringing these concerns to my attention. HELEN WHATELY 4 https://www.dental-referrals.org/dentists/cancer/ 5 https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/09/guid-comms-oral.pdf 6 https://www.dental-referrals.org/wp-content/uploads/2017/12/final-NHS-ORAL-CANCER-CARE-with- Acknowledgements.pdf https://www.westsuffolkccg.nhs.uk/wp-content/uploads/2014/08/Head-Neck-suspected-cancer-referral-form- v0.8.pdf https://www.valeofyorkccg.nhs.uk/seecmsfile/?id=1534 7 https://cgdent.uk/wp-content/uploads/2021/08/Standards-in-Dentistry-2018-text.pdf
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