Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0260, written 20 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Jul 2023 |
|---|---|
| Reference | 2023-0260 |
| Deceased | Peter Harris |
| Coroner | Alison Hewitt |
| Coroner area | City of 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.
Re : PETER JOHN HARRIS DECEASED REGULATION 28 REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Radiology Clinical Lead and the Clinical Governance Lead for the Barking, Havering and Redbridge University Hospitals NHS Trust. 1 CORONER I am Alison Hewitt, HM Senior Coroner for the City of London. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST I commenced an investigation into the death of Peter John Harris, aged 73 years, who died at St. Bartholomew’s Hospital, London on the 10th June 2022. The investigation concluded at the end of the inquest on the 11th July 2023. The conclusion of the inquest was that the medical cause of death was – Ia Multi-Organ Failure Ib Recurrent Global Pericardial effusion Ic Metastatic lung adenocarcinoma T4 N2 M1a II Carcinoma Prostate and my conclusion as to the death was – Natural Causes. 4 CIRCUMSTANCES OF THE DEATH My findings as to the circumstances of the death, as recorded on the Record of Inquest, were as follows: 1. On the 11th May 2022 Peter Harris was admitted to Queens Hospital, Romford and was found to have a large pericardial effusion and a diagnosis of stage 4 metastatic lung cancer was made. The condition was untreatable but palliative chemotherapy was planned. However, on the 27th May 2022 and the 3rd June 2022, the Deceased was re-admitted with non- resolving pneumonia which was treated with anti-biotics. His symptoms worsened and he was found to have a recurrent pericardial effusion and, on the 5th June 2022, he was transferred to St. Bartholomew’s Hospital, London for a “pericardial window” to be performed. However, before going to theatre, the Deceased suffered a cardiac arrest. He was resuscitated and intubated, and he underwent an emergency pericardiocentesis before transfer to the Intensive Treatment Unit. Despite support, attempts to wean the Deceased from sedation were unsuccessful, and he developed multi-organ failure and died at 17.30 hours on the 10th June 2022. 2. In 2020, whilst being investigated by the colorectal service at Queens Hospital, a CT scan performed in November 2020 raised the possibility of a malignant process in the lung but this report was not seen by the clinical team. If it had been seen, it is likely that annual review and monitoring would have been arranged and this may have enabled the lung tumour which subsequently developed to have been diagnosed and treated before it reached stage 4. There was, therefore, a lost opportunity to monitor for and, possibly, to diagnose and treat, the lung cancer. However, it is possible that the tumour, which probably developed quickly, would not have been found even by annual review. Consequently, on the evidence, it is not possible to ascertain whether monitoring probably would, or would not, have prevented the Deceased’s death. 5 CORONER’S CONCERNS Background: 1. The evidence at the inquest showed that the results of two separate scans performed on the Deceased, both of which had concerning outcomes, were not seen and acted upon in a timely manner. 2. First, on the 8th October 2020, a Consultant Colorectal Surgeon at Queens Hospital requested a CT scan of the Deceased’s thorax, abdomen and pelvis because the Deceased had reported significant weight loss and other symptoms. The radiologist’s report on the scan, dated the 8th November 2020, mentioned findings of multiple lung nodules and included a differential diagnosis of lung metastases. This outcome was never seen by the requesting clinician, nor any other clinician (including the Deceased’s General Practitioner). I was told that the radiologist’s report was not escalated or alerted to the clinical or multi-disciplinary teams because the requesting form had indicated that the scan was to rule out malignancy; I was told that “the reporter would not raise this as an incidental finding because malignancy was already queried and would expect the referring clinician to review results”. The Consultant Colorectal Surgeon told me, however, that his understanding of the system was that he would be alerted to any finding or suspicion of malignancy. Further, although the Deceased had subsequently been given three outpatients appointments, the error was not picked up through these because all three appointments were cancelled by the hospital and the Deceased was not seen by the colorectal team again. 3. Secondly, a further CT scan of the Deceased’s thorax was undertaken on the 9th April 2022, but the formal report (suspicious for lung cancer) was not made until the 24th May 2022, and this resulting in delay in the Deceased being seen on the cancer pathway by the respiratory team. It seems that the delay in reporting was because a second hospital number had been used for the Deceased when the scan was performed in an external CT scanner located on the King George Hospital site. 4. At the inquest, I heard oral evidence from , and I received documentary evidence, explaining the changes which have been made since the Deceased’s death. The documentation received included an 11 point Action Plan, supported by evidence as to the action that has been taken. On the basis of that evidence, I am satisfied that most of the concerns relating to the Deceased’s scan reporting and other management have been addressed. 5. I do, however, have two ongoing concerns about the system in place for the communication of concerning radiological findings. Steps have been taken to improve the system previously in place. In particular, I have been provided with a copy of the Trust’s new “Radiology Unsuspected Cancers and Critical Findings Protocol” which, I am told, has now been approved, and will be adopted, by the Radiology Clinical Leads and Clinical Governance Leads across North East London. I was also told that a new electronic scan requesting and reporting system will “go live” in August 2023, and that this will enable unexpected cancers and other incidental critical findings to be “red-flagged” directly to the requesting team. The system will also have an “acknowledgment option” enabling the referring doctor to click on a read receipt for all radiology reports. The MATTERS OF CONCERNS are as follows: Concern 1: The Trust’s new policy is concerned with ensuring that unexpected cancer or other critical radiological findings are highlighted to the requesting team. However, the evidence at the inquest suggested that requesting team were not alerted to the suspicious outcome of the Deceased’s November 2020 scan because it was an expected finding; as stated above, I was told that the radiologist’s report was not escalated or alerted to the clinical or multi-disciplinary teams because the requesting form had indicated that the scan was to rule out malignancy and the outcome was not, therefore, treated as unexpected. I am concerned, therefore, that the same could happen again, despite the changes which have been made. I did not consider that was able to address this concern satisfactorily in his evidence. Concern 2: The new electronic system is introducing a “read receipt” feature which, if used, would enable identification of reports which have not been opened and read by the requesting team in a timely manner. I am concerned, however, that the use of the read receipt is optional as this will inevitably undermine the extent to which any monitoring system will be able to spot and identify unread reports. I did not consider that either , nor the Consultant Colorectal Surgeon from whom I heard evidence about the plans for monitoring in the surgical department of Queens Hospital, were able to address this concern satisfactorily in their evidence. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths by addressing the concerns set out above and I believe your organisation has 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 the 14th September 2023. I, as 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 Family of Peter John Harris. I am also under a duty to send the Chief Coroner a copy of your response. 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 by the Chief Coroner. 9 20th July 2023 Alison Hewitt
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.
Executive Offices, Trust Headquarters Queen's Hospital Rom Valley Way, Romford, RM7 0AG PRIVATE & CONFIDENTIAL By Email HM Coroner 14 September 2023 Dear The concerns of HM Coroner are recognised and have been considered. This response will describe actions that are proposed or those that have already been taken to prevent future deaths by addressing the concerns set out below. This response has been devised using the Principles and Recommendations of a Fail-Safe Result Notification System1 as reference with input from the Radiology Leadership Team. A version-controlled Action Plan will be developed, tracked, and communicated so that all actions are SMART, coordinated, prioritised, and shared with key stakeholders. Concern 1: The Trust’s new policy is concerned with ensuring that unexpected cancer or other critical radiological findings are highlighted to the requesting team. However, the evidence at the inquest suggested that requesting team were not alerted to the suspicious outcome of the Deceased’s November 2020 scan because it was an expected finding; as stated above, I was told that the radiologist’s report was not escalated or alerted to the clinical or multi-disciplinary teams because the requesting form had indicated that the scan was to rule out malignancy and the outcome was not, therefore, treated as unexpected. I am concerned, therefore, that the same could happen again, despite the changes which have been made. I did not consider that address this concern satisfactorily in his evidence. was able to 1. The Radiology department will alert/notify the referrer’s/requesters to all imaging with: a. Expected, Unexpected, or Newly Detected Cancer b. Unexpected Critical or Significant Non-Cancer Findings. The referrer/requester will be notified with either a CANCER alert for the expected, unexpected, or newly detected cancer and cancer recurrence, or CRITICAL alert for expected or unexpected findings. This will be sent electronically via Aptvision2 to the referrer/requester (*Verbal Escalation is required when there is an Emergency Critical Finding <1 hour). This will be irrespective of patient type i.e., Inpatient, Outpatient or if the Patient is on a Cancer or Urgent Pathway. In May of this year (2023) the Radiology Unsuspected Cancers and Critical Findings Protocol – BHRUT - Version 83 was reviewed and updated to reflect this change in process. This was communicated to all Consultants in the Trust by the Clinical Lead for Radiology via email (17 May 2023) with a second communication detailing the change sent by the Chief Medical Officer (02 June 2023). Concern 2: The new electronic system is introducing a “read receipt” feature which, if used, would enable identification of reports which have not been opened and read by the requesting team in a timely manner. I am concerned, however, that the use of the read receipt is optional as this will inevitably undermine the extent to which any monitoring system will be able to spot and identify unread reports. I did not consider that either the Consultant Colorectal Surgeon from whom I heard evidence about the plans for monitoring in the surgical department of Queens Hospital, were able to address this concern satisfactorily in their evidence. , or It is the responsibility of the requesting doctor and/or their clinical team to read and act upon the report findings and fail-safe alerts as quickly and efficiently as possible. This extends to ensuring robust mechanisms are in place and resourced to cover leave within clinical teams or practices. 1. Aptvison Radiology Referral System – this new Radiology Requesting System is planned to live week commencing 30 October 2023. 2. Acknowledgement Feature – Following a finalised radiological report, alongside any urgent notifications produced by radiology, an “acknowledgment” button is available. The “acknowledgment” button functionality allows all referrers involved in the initial radiology request to electronically select and acknowledge the receipt of the patient’s radiological report. The referral portal4 training material and learning outcomes for users, will emphasise the requirement of acknowledging results. 3. Viewable WorkLists – It is planned that a viewable worklist of requested imaging and radiological report by referring location /area will be available in the initial release of the referral portal. A secondary release is planned to allow consultants/referrers to view a worklist based who was involved in the requesting process e.g., individual consultant or a group of named team members. 4. Oversight of Reporting - Speciality Specific Reports – Requesting Specialties will be provided with direct access to Business Information (BI) reports summarising a list of patients for whom results have not been acknowledged by the requesting clinician. Once access has been provided, each of the Clinical Groups (CGs) will use the information for local discussion and management through their own Governance/ Quality and Safety meetings. A fortnightly status update will be produced and fed back to each of the CGs/ Specialties highlighting those reports that have not been read at 7 days. It is anticipated that the SitRep will include: • The average time of review. • Reports that have not been read and by whom. • Requesting numbers • Any rejected scans or not completed scans and the reason why. Areas with high locum usage across the Trust will be identified and the responsible CGs will locally assess the potential clinical risk of having a transient workforce. The CGs will be expected to understand and articulate if there is a risk to clinical care and to ensure mitigation is in place to eliminate this risk. 5. Speciality Specific Mailboxes – will be created by the Specialties. This is as an additional safeguard where the notification of imaging report will be sent to a group email in addition to the named consultants individual worklist. Access to shared mailbox will be agreed by the Specialty. 6. Chief Medical Officer Message - To facilitate prompt review, acknowledgement, and action on all imaging reports by referrers. The CMO (or nominated deputy) will inform each CG of the requirement that each of the Specialties within their CG must identify within the specialty teams who the reports will be sent to. This must include Consultant responsible and key Personnel e.g., secretary/Multi-Disciplinary Team (MDT)/Patient Pathway Manager (PPM) and Clinical Nurse Specialist (CNS), this will be decided by each speciality. Consideration of annual leave/sickness and staff turnover will be included. The Radiological Requesting, Review and Expectation process as detailed in this response will be added to the New Consultants 3-day Induction programme run by the CMO. 7. Collaborative Working - On 04 July 2023 Dr Ghadge, Consultant Radiologist and Clinical Lead for Radiology, presented the BHRUT’s Policy on Incidental Finding at the North-East London (NEL) Clinical Leadership Group for peer review. This group’s membership comprises of the Quality and Safety Leads (Consultant grade) from Whipps Cross Hospital, St Bartholomew Hospital, the Royal London Hospital, the Homerton and Newham Hospital. The progress made by BHRUT was recognised and the group members agreed to devise a Unified Incidental Finding Policy across NEL. At the last meeting (01 September 2023), it was agreed that a policy for Cancer Alerts would be developed whereas Critical non-cancer alerts would vary as per local needs. The next meeting planned is 01 December 2023. References 1. Alerts and Notification of Imaging Reports. Recommendations. Academy of Medical Royal Colleges. October 2022. (Document to be added to response). 2. At BHRUT the electronic web based, integrated Radiology Information System (RIS) from Aptvision provides a platform for verifying appropriateness of requests for radiology investigations, protocoling radiology examinations to answer the clinical question, booking the exam and recording the report of radiology exams. It can also be used to share vetting responsibility across the teams where the priority of a request upgraded to a more urgent based on the clinical history provided by the clinical team. The different steps of this process are visible to all referring doctors creating greater visibility of requests and where they are in the process. 3. Radiology Unsuspected Cancers and Critical Findings Protocol. BHRUT. Version 8. May 2023. (Document to be added to response). 4. As a Trust we are working towards providing an Electronic Requesting Portal for Radiology. This digital platform will facilitate a digital means for clinicians/referrers to electronically request radiological imaging within the Trust. Referrers can then easily track the status of their referrals through various stages i.e., Vetting, registered, examined, all the way to reported and can also communicate bi-directionally to convey more information, cancellation reasons and alternative imaging changes. All the previously mentioned communications constitute are reflected as “Alerts” which will be displayed on a dedicated page within the portal. There is also the capability for results to be acknowledged by, you as a refer or responsible episode consultant have read the report the findings. Additional documents (to be added to response) 5. Solitary Pulmonary Nodule Clinic Standard Operating Procedure (SOP). This document has been included to provide further assurance to HM Coroner regarding the management of lung nodules highlighted as an incidental finding. This process was approved after the Serious Incident and demonstrates that there is process in the Trust for the management of Incidental Findings of nodules. 6. meeting Presentation to NEL Peers 04 July 2023 at the North-East London Clinical Leadership Group 7. Agenda for the North-East London Clinical Leadership Group meeting on 01 September 2023. 8. Action Plan. Further Information: The demand for Diagnostic and Intervention Radiology at Barking, Havering and Redbridge University Trust (BHRUT) continues to grow with 535,000 radiology requests received in the last financial year 2022-2023 and 363,664 so far this year to date. Figure 1 – Radiology Requests from 2018 – 2023 (current) Sum of EXAMS by Imaging Modality Year CT 2018 2019 2020 2021 2022 2023 Grand Total 60,750 64,715 61,673 76,488 81,942 50,222 395,790 Fluoro- scopy 10,749 10,521 8,494 9,326 9,767 6,216 55,073 MRI Non obstetric US 120,756 127,450 80,181 89,535 96,184 73,903 38,478 43,546 33,733 38,738 45,984 29,036 229,515 588,009 Obstetric US Radio no Fluoro Radio- Isotopes Grand Total 54,513 61,779 50,570 58,335 63,763 38,077 327,037 277,475 279,465 214,777 251,912 259,147 162,533 1,445,309 32,922 6,802 6,705 4,405 5,372 5,961 3,677 569,523 594,181 453,833 529,706 562,748 363,664 3,073,655 This places huge demand on this service and across the wider Trust (e.g., urgent radiological referrals for Cancer diagnosis and Cancer management, Outpatient GP referrals and Emergency Department imaging). A Trust wide approach is required to ensure that a robust reporting system is in place. Yours sincerely, Chief Executive
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