Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0164, written 1 Jun 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jun 2022 |
|---|---|
| Reference | 2022-0164 |
| Deceased | Angela Maguire |
| Coroner | Lydia Brown |
| Coroner area | West London |
| Category | Hospital Death (Clinical Procedures and medical management) 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Family 2. Chief Coroner 3. NHS England 4. Kingston Hospital NHS Trust 1 CORONER I am Lydia Brown, Acting senior coroner, for the coroner area of West London 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 22 April 2021 I commenced an investigation into the death of Angela Maguire, aged 84. The investigation concluded on 26 April 2022. The conclusion of the inquest was death due to natural causes, the medical cause of death being 1a Upper Gastrointestinal haemorrhage 1b Metastatic Cholangiocarcinoma II Ischaemic heart disease, Atrial Fibrillation 4 CIRCUMSTANCES OF THE DEATH Mrs Maguire became unwell and was referred to Queen Mary's hospital, London for a CT scan, performed on 31 March 2021. She then deteriorated and was taken by ambulance the following day to Kingston Hospital and admitted. Her symptoms suggested a malignancy, but this was not confirmed as the first scan was not accessed and a further CT scan was interpreted only partially. Additional tests were ongoing and clinical signs all supported the working diagnosis, so her supportive treatment was appropriate apart from a lack of senior oversight regarding her anticoagulation medication. On 7th April 2021 she began to display signs of an upper gastro-intestinal bleed, and she then deteriorated rapidly and died the following morning on 8th April in Kingston Hospital. 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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The clinicians assisting with the inquest advised the court that there was no system to share radiology across the Region. In West London, patients are frequently transferred from hospitals to access particular specialisms of care, such as cancer care. In this case, the previous images taken at Queen Mary’s Hospital, London, could not be accessed across a common link by Kingston Hospital, Surrey and therefore the opportunity was missed to see and compare previous images. While this did not have an impact on the 1 outcome in this case, it could have very significant consequences and lead to missed diagnoses and potentially fatal outcomes of untreated disease processes. In this case the opportunity to offer palliative care and advise the relatives of end of life treatment was lost. The lack of a shared portal also creates further work for clinicians who have to contact the previous hospitals to access this information. There are many shared systems in place in the NHS for cross-site sharing of images and reports, and it was not clear from those assisting the court at this inquest why similar systems are not currently in place for this Region and not anticipated for “several more years”. 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, 2 namely by 1st August 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: Family, NHS England, Kingston Hospital NHS Trust I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 1st June 2022 SIGNED BY CORONER Signed by Acting Senior Coroner Mrs Lydia Brown 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.
Mrs Lydia Brown
Acting Senior Coroner
West London Coroner’s Service
25 Bagleys Lane
Fulham
London
SW6 2QA
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
6 October 2022
Dear Mrs Brown
Re: Regulation 28 Report to Prevent Future Deaths – Angela Maguire who died
on 8 April 2021.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1 June
2022 concerning the death of Angela Maguire on 8 April 2021. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Angela’s family and loved ones. NHS England are keen to assure
the family and the Coroner that the concerns raised about Angela’s care have been
listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise to
the family for the delay, as I appreciate this will have been an incredibly difficult time
for them.
Following the inquest, you raised concerns in your Report regarding there being no
system for sharing radiology across the Region, meaning that the previous images
taken at Queen Mary's Hospital, London, could not be accessed across a common
link by Kingston Hospital, Surrey. It was noted that there are many shared systems in
place in the NHS for cross-site sharing of images and reports, and it was not clear why
similar systems are not currently in place for this Region and are not anticipated for
“several more years”. Whilst this issue did not impact on the outcome in this case, it
could have very significant consequences and lead to missed diagnoses and
potentially fatal outcomes of untreated disease processes. In Angela’s case, the
opportunity to offer palliative care and advise her relatives of end of life treatment was
lost.
The NHS Long Term Plan committed to establishing Imaging Networks across
England by 2023. Currently, the 22 Imaging Networks across England are being
supported to increase their maturity, with a specific focus on the sharing of imaging
history, reports and the images themselves.
The National Imaging Strategy, published here in November 2019, outlined how the
formation of Networks would improve access to specialist opinion and introduce
technologies to allow all digital images acquired within the Network to be managed by
a single shared worklist, allowing them to be shared and reported by any organisation
within the Network or beyond. This would ultimately result in better access for patients
to imaging services, and would allow greater collaboration with clinical pathways so
that patients can engage with treatment earlier.
Each Imaging Network is responsible for assessing their own maturity against a
maturity matrix, with the aim of having 70% at a “Maturing” level by the end of the
financial year 2024/5. By reaching a “Maturing” level, this means that the Networks
will be “jointly working across the Network with the implementation of a network level
plan underway”.
At maturing level, Networks will enable Trusts to:
• Search and view a patient’s imaging history and reports from all main local NHS
imaging service providers
• Access all results and history held by the Imaging Network for authorised
clinicians in other care settings (e.g. community care)
• Access all results held by the Network for the patient
• Routinely report at any site through the use of a single “global” worklist
• Work on solutions to unify workflow and have adopted common coding
In the interim, Trusts are able to use the Image Exchange Portal which has been the
system to share images for ten years
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Angela, are shared across the NHS at both a national and regional level, and helps us
to pay close attention to any emerging trends that may require further review and
action.
We have not had sight of a response from the Kingston Hospital NHS Trust, but if one
is received then this will be considered further by the Regulation 28 Working Group,
to better understand any particular challenges faced by the Region and so that NHS
England can support any action being taking to prevent future deaths.
Thank you for bringing this important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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