Calogero Di Blasi

The Rt Hon. Andrew Stephenson CBE MP 
Minister of State 

39 Victoria Street 
London 
SW1H 0EU 

                 5th March 2024 

Dear Debbie,  

Thank you for your letter of 15 November 2023 about the death of Calogero Di Blasi. 
I am replying as Minister with responsibility for Health and Social Care.   

Firstly,  I  would  like  to  say  how  saddened  I  was  to  read  of  the  circumstances  of 
Calogero Di Blasi’s death and I offer my sincere condolences to their 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.  The  matters  of  concern  you  raise  relate  to  the  local  management  and 
implementation  of  national  policies  and  procedures.  As  such,  I  requested  NHS 
England  liaise  with  the  North  Somerset  and  South  Gloucestershire  Integrated  Care 
Board (ICB) responsible for University Hospitals Bristol and Weston NHS Foundation 
Trust.  

From advice received from NHS England, my understanding is that the ICB has looked 
into the circumstances of Mr Di Blasi’s death and acknowledges the findings set out in 
the coroner’s report. I understand that the ICB has made several recommendations to 
the Trust to address the issues in question which I hope will help the trust to ensure 
that the events leading up to Mr Di Blasi’s death will be avoided in the future of care 
of other patients. I understand the Trust also plan to write directly to you setting out 
action they have planned, and taken locally, in response.  

Since  the  death  of  Mr  Di  Blasi,  NHS  England  and  the  Department  have  reformed 
cancer waiting time standards, following a clinically led review. This has replaced the 
two-week wait standard with the Faster Diagnosis Standard (FDS) for patients to get 
a cancer diagnosis or all-clear within 28 days of an urgent referral. The FDS moves 
focus  away  from  process  to  deliver  a  clear  clinical  outcome  –  either  diagnosing  or 
ruling  out  cancer.  This  represents  an  improvement  on  the  preceding  2-week  wait 
standard, which was simply to “see a specialist” and addresses the coroners concerns, 
as the new standard takes into account times for reporting and reviewing diagnostic 
procedures.    The  reform  also  consolidated  cancer  standards  from  nine  to  three  to 
reduce bureaucracy of reporting against a large number of standards.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I hope this response is helpful. Thank you for bringing these concerns to my attention.  

Kind regards, 

THE RT HON ANDREW STEPHENSON CBE MP 
MINISTER OF STATE

Trust Headquarters 
Marlborough Street 
Bristol BS1 3NU 

10 January 2024 

Ms Debbie Rookes 
Assistant Coroner for Avon 

PFD RESPONSE 

Dear Ms Rookes, 

Deceased: Calogero Di Blasi 

I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 15 November 
2023. 

I would like to begin by extending my deepest condolences to the family of Mr Di Blasi. I hope that 
my response provides his family with assurance that the Trust takes their loss seriously and has 
taken this further opportunity to consider actions which may prevent this from recurring. 

In order to respond to the matters of concern set out in your report and provide assurance to you 
on the actions taken to mitigate the risk of future deaths, I have sought the assistance of 

 Chief Clinical Information Officer. In addition, I have consulted with 

, 
Clinical Chair for the Division of Surgery, who has clinical responsibility for the Colorectal and 
Upper GI teams, and 
the inquest and has clinical responsibility for Radiology. 

, Clinical Chair for Diagnostic and Therapies, who was present at 

Matters of concern 

1)  Issues arising from parallel clinical pathways 

I acknowledge your concern around the communication between specialties when a patient is on 
two active pathways. I recognise the importance of such knowledge, given the increasing 
complexity of the patient demographic we treat. 

I understand that you heard evidence from the clinical team around the additional question on the 
pre-procedure checklist for endoscopy. A patient is now asked whether they have had any 
investigations within the last 6 weeks, and I was pleased to hear that this has been effective in 
identifying such investigations. 

 
      
 
 
 
 
 
 
 
 
 
                   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 
 
 
  and the witnesses to consider whether any further action could be taken to 

I asked 
strengthen the pre-procedure checklist. I am advised that they have identified an additional 
potential change in practice. The Division of Surgery will undertake a scoping exercise to assess 
the feasibility of the administrative teams reviewing the patient list and identifying any patients who 
are on a parallel clinical pathway. The endoscopist would then be notified to review the electronic 
records and ICE and any relevant investigations before the procedure. Upon completion of the 
scoping exercise, the Division will consider whether a pilot may be offered for the endoscopy team. 

As many patients are treated out of the region or in private or satellite institutions, the subsequent 
check by the clinician, through a discussion with the patient, provides another opportunity to 
identify relevant investigations, thereby ensuring there is a robust process in place. 

I trust that this is striking the balance between maintaining the number of investigations for those 
patients on the urgent referral pathway, whilst ensuring that relevant investigations are identified 
for each patient. 

2)  The reporting timeframe on two 2 week urgent cancer pathway referral does not take 
into account timeframes for reporting investigative procedures or subsequent review 
by the referring clinicians. 

As you heard in evidence, there is, regrettably, a national shortage of Radiologists. I therefore 
envisage that the Secretary of State for Health may wish to add to the below response from the 
Trust. 

Firstly, I attach the guidance on diagnostic imaging reporting turnaround times issued by NHSE in 
August 2023. Whilst this national guidance was issued after Mr Di Blasi’s death, it provides a 
maximum turnaround time of 3 days for outpatients on a cancer pathway. 

The Trust recognises that this best practice relies upon there being full staffing available to deliver 
it. Furthermore, the guidance considers that adherence to the turnaround times relies upon good 
digital connectivity and IT infrastructure; I will turn to the Trusts’ digital strategy below. 

Regrettably, in parallel with a number of organisations across the country, the Trust is not meeting 
this timeframe. The following mitigations have been put in place: 

•  The Trust is actively recruiting to the vacancies for radiologists. 
•  Outsourcing is used to maximise the number of reports which can be achieved within the 

timeframe 

•  Locum radiology cover can be arranged. 
•  Additional sessions are in place for existing radiologists 
•  The Division is undertaking a scoping exercise to increase the resource of radiographers 

who could support the radiologists. 

All of the above actions will increase reporting capacity and seek to enact the recommendations 
from the national guidance. In addition, the Radiology team have added a risk to the risk register 
around turnaround times. This will ensure that this remains a priority for the Division. 

Secondly, the guidance confirms that local Standard Operating Procedures (SOPs) should identify 
‘urgent’, ‘emergency’ and ‘time critical’ findings. You heard in evidence that the Trust’s SOP on 
Incidental Findings will be reviewed, with a view to updating this to reflect the recent national 
recommendations of the royal colleges. 

 
      
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
   
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 Aligned to this, I have received an update in respect of the paper reports for radiology; these will be 
discontinued from 1 May 2024. Results will continue to be available via the ICE and PACS 
electronic reporting systems. As part of the transition away from paper results, the Trust plans to 
set up specialty specific reporting systems within our existing digital platforms. 

Alerts 

I thought it important to update on the action the Trust has considered but would be unable to 
implement. 

I understand that it was explored in evidence whether an alert could be added to the electronic 
records for varices. It would not be practicable to highlight chronic conditions in alerts. 
Notwithstanding the fact that their purpose is to identify standardised alerts, such as allergies and 
the need for an interpreter, expanding this to include a new diagnosis, would not be feasible. 
Furthermore, it may be helpful to explain that the alerts do not pop up when a clinician opens the 
electronic record, they must be accessed, and there is a risk that adding new alerts could increase 
risk. 

The Trust has therefore carefully assessed this option but considers that it would not improve 
patient safety and would be outwith our understanding of how other Trusts are utilising alerts on 
electronic records. 

3)  The current training for Endoscopists for JAG accreditation requires the 

performance of 200 endoscopies. However, these tend to focus on clinician’s area of 
specialty and therefore there is danger that lesion recognition will be limited and 
insufficient to ensure that endoscopies are able to recognise less frequently 
occurring lesions. With the need for an increasing number of endoscopists, action 
should be taken. 

I note that the Regulation 28 Report was shared with the Royal College of Physicians, who I 
understand are responsible for the Joint Advisory Group on GI Endoscopy (JAG) and will be 
providing you with a response from a national perspective. 

The Trust has taken further action, over and above those completed for the PSII, to address this 
concern: 

• 

 operates 5 training lists each week, in his capacity as Clinical Lead. He is able to 

share his knowledge of lesion recognition with junior doctors, to build upon the 200 
endoscopies they are required to take in their own training. The current schedule includes 
10 dedicated training lists, in addition to ad-hoc training and hosting fellows in Lower GI 
Endoscopy and Advanced Hepatobiliary Endoscopy. The Trust collaborates with other 
Bristol endoscopy institutions to provide training courses on upper gastrointestinal 
haemostasis and colonic polypectomy, both JAG-certified courses. Trainees of all 
endoscopic disciplines are encouraged to attend lists where they are likely to encounter a 
broad range of pathology. 

•  Learning from this case has been shared at our pan-UHBW Endoscopy Users Group 
(EUG), in addition to local Gastroenterology and Hepatology education meetings. 

 
      
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
   
 
 
 
 
 
 
 
 
 
 
  
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 •  Endoscopists have access to an online endoscopy learning platform (GIEQs online; 

accredited by the European Society for Gastrointestinal Endoscopy (ESGE) and American 
Society for Gastrointestinal Endoscopy (ASGE)). We are able to audit uptake of the online 
content prior to quarterly EUG meetings. We are also collaborating with the South-West 
Endoscopy Training Academy (SWETA) to create a mandatory local learning resource that 
will form a part of the Trust statutory training for staff involved in gastrointestinal endoscopy. 
•  The PSII has also been shared at the Patient Safety Group, which has representation from 

all of the Clinical Divisions at the Trust, to ensure learning is cascaded across all 
specialties. 

Digital Strategy 

UHBW and NBT will shortly appoint a joint Chief Executive and Chair. The Chief Digital Information 
Officer has already been appointed across both Trusts and is in the process of launching a Digital 
Strategy, with the aim of converging the IT systems across the provider collaborative. 

As a tertiary centre, the Trust receives referrals from across the region and recognises the 
importance of integrated working. The challenge of multiple systems for records is a national one. 
The overarching aim of the strategy will be to ensure that clinical information is digital and in one 
place, thereby avoiding paper records. I therefore hope that you will begin to see a united 
approach across the two Trusts who serve the jurisdiction. I am hopeful that the improved 
infrastructure will help to support the delivery of the turnaround times discussed above. 

I understand that Mr Di Blasi’s family requested that the learning from this inquest be shared with 
the Clinical Endoscopist who performed the first endoscopy, but who no longer works at the Trust. 
The Trust will endeavour to achieve this. Lastly, it may be helpful to confirm that the Endoscopy 
team is auditing photo documentation during an endoscopy as part of the recurring audit plan. 

We trust that the above actions provide you, and the stakeholders you have shared the Regulation 
28 Report with, assurance that the Trust has learnt from this death. We are consistently 
challenging ourselves to consider further action we can take to strengthen patient safety, whilst 
recognising that a number of the concerns raised are at a national level. 

Yours sincerely 

Interim Chief Executive