Michael Daft

Please ask for the Medical Director’s Personal Assistant 

18th January 2024 

Miss Sarah Wood 
HM Assistant Coroner for Nottingham City and Nottinghamshire 
HM Coroner’s Court 
The Council House 
Market Square 
Nottingham   NG1 2DT 

Dear Miss Wood 

Medical Director’s Office 
3rd Floor, Trust Headquarters 
City Hospital Campus 
Hucknall Road 
Nottingham 
NG5 1PB 

www.nuh.nhs.uk 

Inquest: - Michael Daft- Prevention of Future Death Report [PFDR] Response 

I  am  writing  in  my  capacity  as  Medical  Director  of  Nottingham  University  Hospitals  NHS  Trust  in 
response to the Prevention of Future Deaths Notice issued on 24th November 2023 following the sad 
death of Mr Michael Daft.  

May I begin with offering my sincerest condolences to Mr Daft’s family for their loss. I am deeply sorry 
for the missed opportunities and issues that were highlighted during the Inquest.   

The  concerns  you  have  raised  have  been  taken  extremely  seriously.  Please  find  attached  a 
commentary  in  response  to the  Prevention  of  Future  Deaths  Report  issued  to  Nottingham  University 
Hospitals NHS Trust following the inquest into the death of Mr Daft.  

My  response  to  the  concerns  identified  in  the  PFD  report  have  been  informed  following  work 
undertaken  by  colleagues  within  the  Patient  Safety  Teams,  Surgical  and  Cancer  and  Associated 
Specialties (CAS) Divisions and the Cancer Centre Team.  

The  actions  either  taken  or  planned  in  response  to  the  learning  from  the  inquest  are  summarised 
below.  The  oversight  of  the  delivery  of  these  actions  will  be  through  our  Quality  and  Safety 
Governance Committees, with Executive oversight - Committees of our Board will receive a progress 
report. 

I hope that this commentary provides assurance that we are committed to learning from this, and other 
incidents to significantly enhance the care of patients across the Trust.  

Yours sincerely 

Medical Director [NUH]  

Encs 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 Concerns identified through the PFDR 

The matter of Concern is: 

There is little evidence to date of effective communication between Multi-Disciplinary Teams (MDT) from 

different specialisms when a patient in on more than one treatment pathway 

Response to the concerns identified through the PFDR 

MDT outcomes have become an area of concern based on a number of Datix reports and Serious Investigations 

including  this  case.  Early  issues  that  have  been  highlighted  include  varying  scenarios  of  how  outcomes  are 

communicated across all MDTs differently both internally and externally, and how MDT’s communicate with each 

other. Considerable work has already been undertaken, particularly around cancer pathways.  

In response to the PFD regarding Mr Daft the following actions are relevant: 

Safety Snippet  

-  The Safety Team have composed a ‘safety snippet’ (a succinct safety briefing) distributed across the Trust 

to  remind  colleagues  of  the  potential  risks  to  patients  on  multiple  speciality  pathways,  particularly  when 

waiting times for investigations are prolonged. The importance of communicating the need for prioritisation 

of  investigation  with  reference  to  clinical  concern  and  potential  impact  of  deterioration  of  the  presenting 

condition has been highlighted.   

Trust-wide learning 

-  This case had been discussed within the Colorectal and Urology services, across two clinical divisions and 

will be presented to the Governance teams at the Mortality and End of Life Group (MEOLG) meeting on 1st 

February  2024.  This  was  due  be  presented  at  the  meeting  at  the  beginning  of  January  but  this  was 

rescheduled as a result of industrial action. 

Operational response 

-  The Trust is currently engaged in a MDT Excellence Initiative and is due to deliver on this in a number of 

areas over the coming  year. This project is initially  looking at building  on existing baseline  work aiming to 

reduce variation in referral processes internally & externally across all tumour sites with focus on addressing 

the lack of adequate information on referrals received which causes delays.  The second phase will look at 

standardising all MDT processes.  

-  A few specifics of the project are described below along with the attached PowerPoint file that demonstrates 

the work we are undertaking currently and going forward: 

 
 
 
 
 
 
 
 
 
 
 
 
 
   All Cancer MDTs at NUH will have MDT referral in place on Careflow by August 2024: We have a 

minimum of 34 MDTs that need to be able to refer via the NUH digital system. We have 19 sites that are 

already  live  and  up  and  running,  5  sites  that  are  in  consultation  /  building  phase  and  7  areas  that 

requiring scoping. These 7 sites are at the end of the schedule due to them having an involvement with 

tertiary centres or are a regional MDT so require more planning.  

  Cancer  MDTs  which  receive  referrals  directly  from  Pathology  department  to  have  Pathology 

Medway referral in place by  August 2024: We have a minimum of 34 MDTs that need to be able to 

refer via the NUH digital system direct from pathology. We have 8 sites built and 6 in use as of January 

2024. The role out of these referrals subsequently will be implemented quickly as is a standardised form.  

  Agree  and  pilot  a  standardised  process  for  MDT  referrals  between  Trusts  by  October  2024: We 

have already completed an initial scope and started discussions around tertiary referrals and are in the 

process of writing a business case for a digital system ‘Refer a patient’ for external referrals for MDT to 

NUH. This is fully auditable, contains a timeline of patient activity and minutes can be sent direct back to 

referred in a timely manner. Once a patient has been referred via this system, any activity that happens 

the  referrer  will  receive  either  an  SMS  alert  or  email  that  an  activity  has  taken  place  including  when 

minutes and actions can be assigned following MDT. 

  Agreed  Standard  Operating  Procedures  (SOPs)  for  individual  MDT’s  to  be  written  with 

overarching MDT SOP to standardise the MDT process: Work is currently taking place on writing the 

overarching MDT SOP in conjunction with the Cancer Centre management team, Lead Cancer Clinician 

and other members of the MDT excellence project group. The overarching MDT SOP deadline is March 

2024 and a plan is to complete 2-3 individual MDT SOPs a month. We have already started work on the 

individual SOPs and already completed 2-3 last month.  

  Reporting and query/process mechanism in place: Work will be carried out to set up an audit of MDT 

referral numbers within NUH (new and review), look at the amount of times a patient is referred to MDT 

and the effect this has on a patient pathway so we can learn from the themes and review any referrals 

as an ongoing process. 

 

 MDT outcomes and distribution process: Work has already started at looking at how MDT outcomes 

are  distributed  and  work  will  take  place  in  line  with  Information  Governance  procedures  and  the  MDT 

excellence project to streamline this process both internal and external. This is of particular relevance in 

this case. Currently the internal process within the Cancer Centre, is to send all outcomes to the agreed 

core member distribution list. If a referrer is outside of the agreed core membership they will only receive 

the  information  on  the  patient  they  have  referred  with  via  NUH  email  or  NHS.Net  if  external.  The 

outcomes are also uploaded for NUH patients within NotIS, once verified, within 48 hours. Going forward 

we  will  be  moving  to  a  Web  based  MDT  system  within  Infoflex  (database  and  patient  management 

system for patients with cancer) and the minutes will be verified live in the MDT meeting, causing less 

delays on the outcomes being sent back to referrer (as detailed in the PowerPoint document attached). 

  Training  and  sharing:  As  documents  and  IT  work  are  completed  the  Cancer  Centre  are  supporting 

training  and  will  be  working  on  an  agreed  in  house  training  programme  for  new  starters  and  also  to 

provide refresher training to in house MDT coordinators that again can be shared with  Divisions to help 

 
 standardise the training of MDT coordinators across the Trust.   The Cancer Centre will also support all 

areas with this.  

  Digital  work:  A  web-based  version  of  Infoflex  is  currently  being  developed  so  that  MDT  co-ordinators 

will be able to access Infoflex during their MDT meetings, record outcomes and have these checked by 

the MDT lead and uploaded as the patient is being discussed during the meeting to avoid any delay to 

patient  care.  This  is  being  facilitated  by  the  CAS  Data  Manager  with  support  from  the  Project  Lead, 

Project Support Officer and the MDT Excellence project. 

 

In addition to all the above work we also have a regular MDT excellence meeting on a monthly basis as 

briefly mentioned. This meeting has one or more representatives present form each clinical division that 

feed their expertise in to the process of the MDT to help standardise the process across board.  

  The Project Lead has monthly meetings with the Divisional Management Teams around all areas related 

to Cancer, including MDT so they are kept up to date of project work and can disseminate to the teams 

of ongoing work.  

MDT Oversight Group (MDTOG)  

- 

In  order  to  support  the  above  project  the  Deputy  Medical  Director  has  requested  quarterly  updates  be 

provided  to  the  Quality  and  Safety  Oversight  Group.  An  MDT  Oversight  Group  is  to  be  established  from 

February 2024 to support the MDT excellence work, chaired by a Deputy Medical Director and supported by 

Divisional  Directors,  Cancer  Centre  Clinical  and  Operational  Leads  and  relevant  senior  clinicians.  This 

Group  will  undertake  a  review  of  the  project  status  by  September  2024  to  determine  if  this  needs  to  be 

linked to the Trust’s Safety Priorities as part of the Patient Safety Incident Response Plan (PSIRP) for 2024-

2025.  

Summary 

-  The  actions  set  out  above  are  intended  to  address  the  matters  of  concern  identified  in  the  Prevention  of 

Future Deaths report to improve communications within and across MDT’s.  

I hope this response provides both you and the family of Mr Daft our commitment to learning from this case 

to significantly enhance the care for our patients.