Kathleen Stewart

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Tameside and Glossop 
Integrated Care 
NHS Foundation Trust 

Tameside and Glossop Integrated Care NHSFT 
Fountain Street 
Ashton Under Lyne 
Tameside 
OL6 9RW 

Integrated Governance Unit 
Silver Springs 
Tameside and Glossop Integrated Ca_re NHSFT 
Ashton  Underlyne 
OL69RW 

gth  September 2022 

Mr C Morris 
HM SeniorCoroner 
Man ch ester Sou th  Coron er' s Court 
1 MountTabor Street 
Stockport 
SK13AG 

Dear Mr Morris, 

I am writing fu rtherto_the in qu esttou ch ing upon the death of Kathleen Stewa_rtwh ich con eluded 
on 28th  June 2022 and the subsequent Regulation 28 Report issued to this Trust.  I hope to be 
able to build upon the issued raises within your report, ahd set out below my response. I have 
outlined these in order of the concerns raised. 

Concern 1 

The  court heard evidence that,  whilst the  Middle Grade  doctor who  treated Mrs  Stewart in the 
Emergency Department did not identrfy _any bony injury,  a Radiographer who formally reported 
on  the  pelvic X-Ray the  following  day identified a  minimally displaced  fracture  of the  right 
superior pubic ram us; It is a matter of concern  that this X-Ray report was not acted upon,  and 
as  such  Mrs  Stewart  did not  receive  the  indicated follow  up  of analgesia  and  referral  for 
physiotherapy. 

, 

To  support re~ults governance the Trust has an  established safety workstream,- overseen  by 
the Executive Medical  Director.  The workstream  was  established a  number of years  ago to 
specifically put in  place and monitor improvements and risk involved in results-requesting and 
acknowledgment. The  group reports  directly  into the Service  Quality and Assurance Group 
chaired by myself as the Executive Director of Nursing and Integrated  Governance, which in 
itself is· overseen  by  the  Quality  and Governance Committee,  chaired  by  a  Non-Executive
Director. 

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Integrated Care 
NHS Foundation Trust 

The Trust has in place a system whereby a RadiologistorR~porting Radiographerreviewsand 
reports  on  all  X-Rays  which  have been  requested  from  the Emergency Department.  Where 
the request for an  X-Ray is made by a member of the Emergency Department Team,  the report 
is shared for Emergency Department Consultant review and, where appropriate, further action 
is undertaken.  At the time  Mrs  Stewart was treated  in the Emergency Department there were 
reports  within the Emergency Department awaiting Consultant review, which was contributed 
to  by  the increased activity seen in  the Emergency Department as  a result of the  operational 
response to  Covid-19. 

Whilst the  Trust  has current safety  net procedures  in  place,  we  are  working  to  introduce ·a 
system whereby a Radiologist or Reporting Radiographer will be able to immediately assign a 
level of priority to each  report in the Radiology reporting system,  CRIS. This will be completed 
using a using a Red-Amber-Green  (RAG) rating. 

· 

Where critical or unexpected findings are identified within the radiological images these will be 
RAG rated  Red, and an  immediate alert will be shared with the Emergency Department Team 
for prompt action by the Consultant-on-call. The alert will appear automatically on the patient's 
electronic casualty card.  Where  image findings are  positive·but expected these will be  RAG 
rated Amber and notified to the Emergency Department for action on a daily basis. Where there 
are  no significant findings, these will be notified to  the Emergency Department for action on  a 
weekly  basis.  The  software  to  support  this  electronic  and  automated  function  is  under 
development and is due to  be completed  by the end of September 2022.  Apilot of the system 
in  the  Emergency Department with full testing  and safety  sign-off is due to  be  completed  by 
Monday 10th October 2022.  Once the system is live this will provide real time alerting to critical 
radiology fin din gs. 

A Standard Operating Procedure (SOP)  has been developed to  support the roll  out of this new 
electronic capability, which  provides  an  explanation  of the reporting  and  escalation  process 
and  outlines  the  clinical  responsibilities  of  both  Radiology  and  Emergency  Department 
colleagues. The  SOP  includes monitoring and oversight arrangements to  ensure compliance 
with the process. The SOP also provides clear guidance on the need to  record  action taken in 
relation to  any abnormal results identified after the patient has left the Department,  this will be 
recorded  in  the patient's electronic notes.  The automated  alerting system  will also have the 
capability to  escalate  any un-read or un-acknowledged radiology findings to  operational and 
clinical leads for action. 

Implementation  of the  new process,  and its outcomes, will be  overseen  by the  Medicine and 
Urgent Care Quality and Safety Board in  conjunction with the Clinical Support Services Quality 
and Safety Board.  Divisional updates will be  provided  monthly to  the Trust's  Service Quality 
and  Assurance  Group,  chaired  by  myself  as  Executive Director  of  Nursing and  Integrated 
Governance, until the new process is fµlly embedded. 

iln  the  interim,  to  mitigate  risk  Emergency  Department  Consultant reviews  of all  radiology 
reports  received within the Department is being prioritised and is being monitored on an  daily 
basis by the Urgent Care Clinical Director and Associate Divisional Director,  overseen  t:>y  the 
r-,J  Medicine and Urgent Care  Divisional Quality and  Safety Board.  For those radiology rep_orts 
bD  where an  action is required the Emergency Departmen.t Consultants work with the Urgent Care 
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Tameside and Glossop 
Integrated Care 
NHS Foundation Trust 

Administration  Team  who  will  pro_cess  the  required  action.  This  process  is  completed 
electronically to ensure reports are  acknowledged by the recipient. 

In  the specific context of this case,  I am  aware that that fractured  pubic rami  is treated  non-
surgically. However,  I  appreciate  that Mrs  Stewart's  pain  may  have been  addressed  more 
effectively had the  X-Ray  report  been  acted  upon.  The  steps  outlined within  this letter are 
intended to minimise risks to other patients with a focus on  safety,  quality and experience. 

Concern2 

The  Trust does not appear to  have undertaken  any specific investigation  as to  why  this .was 
the  case. As such,  the  Trust has not taken the  opportunity to:-
a)  Identify what went wrong  in Mrs  Stewart's  case and ascertain what learning can be detived 
from  the  incident; 
b)  Ascertain  whether  this  was  an  isolated  incident or whether  there  was  (or  is)  a  broader 
problem in relation to  acting on  abnormal reports  of clinical imaging (and if so,  the  nature  and 
extent of any such problem); or 
c)  Consider the  fitness  for purpose of the  system  in place within  the  Emergency Department 
for acting on  abnormal reports  of clinical imaging. 

I  woyld  like  to  begin  by  conveying  my  sincere  apologies  that  this  matter  had  not  been 
investigated or identified atthe time of Mrs Stewart's care. 

As a result of yourconcemsoutlin~d above, the Trust has undertaken a retrospective concise 
investigation into Mrs Stewart's case in the form of an  Multi Disciplinary Team (MDT)  learning 
review involving Urgent Care and Radiology. 

· 

The MDT  learning review noted the initial actions undertaken in  the  Emergency Department 
following the inquest; to confirm the number of reports  awaiting review, introduce a process to 
managetheseandforfuturereview.- It was highlightedthatcapacityh~d been made to ensure 
that this important work was being prioritised.  As is outlined above, this is being monitored on 
an  ongoing  basis  by  the  Urgent  Care  Clinical  Director and  Associate  Divisional  Director, 
overseen by the Medicine and Urgent Care Divisional Quality and Safety Board . 

. 

The investigation was informed by an audit of radiology findings, '-!Sing a large random sample 
from June 2022.  In  respect of Emergency Department cliniciansidentifyingfractures, the audit 
found  that  the  Trust  scored  favourably  when  compared  to  the  National  average  (3.1 %,  · 
compared to 3.7%  Nationally).  The audit also identified thatthe small number of fractures not 
identified by  Emergency  Department clinicians were  all  acted  upon  appropriately  when the 
report was received from  a Radiologist or Reporting Radiographer. 

The auditwill be used to informfutureteachingsessionsforjuniordoctors; providing additional 
education in  respect of pubic rami,  lumbar spine and thoracic spine  X-Rays.  These X-Rays 
will  also  be  reviewed  by  a  Consultant on  the  day  of  performanc~  where  received  by  the 
Emergency Departmentpriorto 22:00 hours. This is intended to reduce the occasic;mson whid7 
injuries are not identified by doctors withi·n the Emergency Department. 

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Tameside and Glossop 
Integrated Ca re 
NHS Foundation Trust 

· 

The review also highlighted progress  made in relation  to  the introduction of.a  new process  to 
assign a priority to  radiology reports,  the developmentofthe electronic alerting system and the 
associated SOP  (as outlined in relation to concern  1 that the X-Ray report was not acted upon). 

It  is our intention to  repeat this audit on  a six month  rolling programme  and this will include 
standards to  measure compliance with  the  new SOP  as  detailed  in  the  section  one  of this 
response.  This specific audit has also been  added to  the Trust Audit plan which is overseen 
at the Service. Quality and Assurance Group and the Quality and Governance Committee. 

As a result of yourconcerns outlined above in relation to  incidents, th.e Trust's incident trigger 
lists  have  been  circulated  widely  throughout  the . organisation  with  a  reiteration  of  tine 
importance of incident reporting.  Emergency Department Consultants have been  specifically 
reminded of the need to  report as an incident any missed abnorrnal results. 

In  addition to this, a planned monthly focus on incident reporting is  currently underway across 
the organisation and being led by the Assistant Director of Integrated Governance throughout 
September,  culminating in  the Trust's  Patient Safety Conference on  October 6th  2022.  This 
programme  of  events  and  activities  seeks  to  engage  staff  at  all  levels  and  focusses  on 
identification  of  incidents  or  near  misses,  incident reporting,  acting  on  and  learning from 
incidents. 

The MDT learning panel noted that a review of Mrs Stewart's care by the Learning from Deaths 
Team was undertaken in December2021.  The LearningfromDeathsTeam identified concerns 
that the family and care home had not been informed of the fractured pubicrami and an incident 
form  was completed,  in  accordance with  Trust guidelines. At that time,  work was ongoing to 
improve results govemancewithin -theorganisation;with collaboration between Urgent Care, 
Radiology and  the  Clinical  Information  Team.  There  was  a  risk  on  the  Urgent Care  Risk 
Register  in  relation  to  results  governance,  with  mitigation  and  further  action  recorded. 
Following a discussion with  the  Emergency Department's Clinical Director, the  incident was 
closed, with no further action identified.  It is apparentthat operational pressures as a result of 
our Covid-19 response impacted  upon our oversight of this. 

It  is  considered that  this  could  have  been  handled differently, with  improved  triangulation. 
Detailed actions to improve this h'ave been outlined to you in my letter of 11 th  August2022 and 
you  are  aware that the Trust's  Incident Reporting,  and Incident and  Complaint Investigation 
Policy is  currently being reviewed  alongside the  NHS England Patient Safety Framework  to 
ensure that this aligns. The policy will outline the process for identifying, reporting, managing, 
investigating and learning from patient safety incidents. The purpose of this review of policy is 
to support a systematic,  compassionate and effective resporiseto patient safety incidents;with 
a  clear focus on  learning and continuous improvement.  This work will  ensure accountability, 
compassion, openness and ownership of improvement and will provide a basis for local training 
and development. This policy will describe in  detail the approach  in  place to  ensure that the 
Trust is prepared  for patient safety incidents so that staff understand what to  do and  how to 
behave when an  incidenthappens:This will also include the Trust,  Divisional and Directorate 
governance arrangements (including key organisational roles  and  responsibilities)to  ensure 
an  effective response. 

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Tameside and Glossop 
Integrated Care 
NHS  Foumjation Trust 

I hope th at th is provides you  with  assurance th at th is matter  has been  taken  seriously with  a 
commitment to  improve and learn from these  events.  In  addition to  this,  in September  2022 , 
Mrs  Stewart's case will form  part of a multidisciplinary learning event being held by the Trust. 
We  will seek  to  share the learning from  Mrs  Stewart's case  in  order to  prevent harm  to,  and 
Inevitably,  this  will  include a focus on  incident 
improve  the  experience of,  future  patients. 
reporting, which supports our aims outlined earlier in this letter. 

I  hope you  will feel  that the Trust  has taken  appropriate  action  as  a  result of your findings, 
howevershouldyou wish to discuss ariy aspect of this or seek furtherassurance please do not 
hesitate to con tact me  through the Legal Services Team  on 

Executive Director of Nursing an a Integrated Governance 

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