Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0491, written 1 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Dec 2023 |
|---|---|
| Reference | 2023-0491 |
| Deceased | Anthony Williams |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Tameside and Glossop Integrated Care NHS Foundation Trust |
| 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 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS England 1 CORONER I am Alison Mutch, HM Senior Coroner, for the coroner area of South Manchester 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 3rd May 2023 I commenced an investigation into the death of Anthony Eric Williams. The investigation concluded on the 27th September 2023 and the conclusion was one of Narrative: Died from the complications of bowel cancer not diagnosed and not treated until it had reached an advanced stage. The medical cause of death was 1a) Metastatic Adenocarcinoma of the bowel 4 CIRCUMSTANCES OF THE DEATH Anthony Eric Williams presented at Tameside General Hospital with abdominal pain and was diagnosed with constipation on 7th October 2022.On 12th October a telephone consultation with a GP resulted in further discussion of treatment for constipation. On 3rd November he was found by the GP to have a distended abdomen and was referred on the two-week cancer pathway. CT scans found a mass in his bowel. Biopsies were initially inconclusive for cancer. A PET scan on 8th February confirmed advanced colorectal cancer. A stoma was inserted laparoscopically on 14th February to assist with his bowel symptoms. He was not seen for chemotherapy consideration until 6th March 2023. His health had deteriorated significantly since his referral on the cancer pathway and his suitability for chemotherapy was borderline. The plan was to start it around 17th March. In the period he developed spinal cord compression and received radiotherapy which was given on 21st March. He continued to deteriorate with the cancer having spread into his brain. Chemotherapy was not started until 4th April 2023.He deteriorated rapidly with the cancer having spread aggressively. He died at Stamford Court on 28th April 2023. 1 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 will 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 inquest heard evidence that a national shortage of specialist scanning facilities such as was required in Mr Williams’ case meant that there were delays nationally with the diagnosis of cancers. This in turn led to delays in treatment and poorer outcomes for cancer patients as delays in diagnosis meant that the cancer would often have advanced further, and treatment was less likely to be successful. This was compounded by the fact that additional complications such as cord compression could arise whilst a scan was awaited and that the patient would be less able to cope with treatment such as chemotherapy when it ultimately started. The inquest also heard evidence that there were significant delays nationally in compliance with the two-week cancer pathway which led to poorer outcomes for patients as any delay in treatment reduced the likelihood of a successful outcome. Evidence was also heard that the delay Mr Williams faced between diagnosis and being seen for a plan to be developed was also part of a wider national picture of delay in accessing cancer treatments and again reduced the chances of a successful treatment outcome. 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, namely by 26th January 2024. 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 namely may find it useful or of interest. on behalf of the Family, who 2 I am also under a duty to send the Chief Coroner a copy of your response. 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 Alison Mutch HM Senior Coroner 01.12.2023 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.
Alison Mutch
Manchester South Coroner’s Court
1 Mount Tabor Street
Stockport
SK1 3AG
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
t
22 January 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Anthony Eric Williams
who died on 28 April 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1
December 2023 concerning the death of Anthony Eric Williams on 28 April 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Anthony’s family and loved ones. NHS England are
keen to assure the family and the coroner that the concerns raised about Anthony’s
care have been listened to and reflected upon.
In your Report you raised the concern that there was a national shortage of specialist
scanning facilities which could cause delays to cancer diagnosis and successful
treatment, that there were delays to compliance with the two-week cancer pathway
and accessing cancer treatments, all of which can impact on treatment outcomes.
In August 2023, NHS England published the Image report turnaround time guidance
available here: NHS England » Diagnostic imaging reporting turnaround times. The
guidance sets out the maximum turnaround times from referral for a number of imaging
services, including position emission tomography CT scans (PET CT). The turnaround
times for PET CT scans for outpatient cancer pathway diagnosis is three days.
The guidance includes caveats for sufficient availability of workforce as the numbers
of reporting staff (radiologists and reporting radiographers) are not increasing in line
with demand. We are supporting Trusts to increase reporting capacity by increasing
the number of reporting radiographers and radiologist trainees per financial year,
international recruitment initiatives and workforce demand and capacity planning
tools.
In August 2022, NHS England published the Delivery plan for tackling the COVID-19
backlog of elective care. The plan sets out how NHS intends to recover elective care
(which includes cancer pathways) over three years with one of the ambitions including
ensuring that 95% of patients who need diagnostic tests receive them within six weeks
of referral. To do this, we have committed to patients having more convenient access
to diagnostic procedures and tests, by developing a network of diagnostic hubs across
England. The plan is supported by a government spend of £8 billion, and this includes
£2.3 billion to help increase the volume of diagnostic activity and reduce patient waiting
times through the roll out of at least 100 community diagnostic centres to help clear
backlogs of people waiting for tests such as MRI, ultrasound and CT scans.
A further follow-up letter setting out Elective Care 2023/24 priorities was sent to NHS
acute Trusts in May 2023, and Integrated Care Boards were asked in April 2023 to
ensure that they were taking steps to prioritise diagnostic capacity for urgent cancer
pathways: NHS England » Prioritising new diagnostic capacity for cancer services.
The ambitions of the elective care of the recovery plan will be reiterated in the NHS
Planning Guidance for 2024/25 which sets out the national objectives for the year. This
has not yet been published but is expected February 2024.
In June 2023, NHS England also published the NHS Long Term Workforce Plan, in
response to the current lack of sufficient workforce. The plan sets out how we will train,
retain and reform healthcare staff across the NHS over the next fifteen years, and is
underpinned by the biggest recruitment drive in NHS history which will further improve
service capacity and delivery.
As part of the NHS reform of cancer standards, it was announced in August 2023 that
cancer targets would be consolidated into three key standards:
•
•
•
the 28-Day Faster Diagnosis Standard (FDS) which means patients with
suspected cancer who are referred for urgent cancer checks from a GP,
screening programme or other route should be diagnosed or have cancer ruled
out within 28 days. This supersedes the two-wait (2WW) standard.
the 62-day referral to treatment standard which means patients who have been
referred for suspected cancer from any source and go on to receive a diagnosis
should start treatment within 62 days of their referral.
the 31-day decision to treat to treatment standard which means patients who
have a cancer diagnosis, and who have had a decision made on their first or
subsequent treatment, should then start that treatment within 31 days.
The FDS includes a non-specific symptom pathway to cover the cohort of patients who
do not fit clearly into a single ‘urgent cancer’ referral pathway, but who may be at risk.
Non-specific symptoms will include abdominal pain such as that experienced in
Anthony’s case. It is the aim that by March 2024 all patients with non-specific
symptoms will be referred via a non-specific symptom pathway.
The Faster Diagnosis Framework provides further information if required. In April
2023, NHS England also published Implementing a timed colorectal cancer diagnostic
pathway guidance for local health and care systems.
NHS England has also engaged with Greater Manchester Integrated Care Board on
some of the elements of Anthony’s care. We are advised that Tameside and Glossop
Integrated Care NHS Foundation Trust have reviewed Anthony’s care and treatment
and have found no requirement for further investigation into diagnosis or subsequent
intervention. It is noted both by the Trust and by NHS England cancer specialists that
Anthony’s cancer unfortunately took an unusually aggressive course.
In Tameside, there is a system-wide Cancer Improvement Programme which focusses
on delivering improved pathways in line with the national priorities. Faster Diagnosis
is one of these national priorities and fundamental to achieving the NHS Long Term
Plan (LTP) ambitions for cancer. Performance for all cancer waiting time standards is
monitored on a monthly basis at an executive led Cancer Improvement Board. This
Board also has oversight of a Cancer recovery plan to support delivery of the national
waiting time targets and the long-term plan priorities.
One of the key elements of improving access to diagnostics for colorectal cancer is
the faecal immunochemical test (FIT) which is used as a screening test for colon
cancer. It tests for hidden blood in the stool, which can be an early sign of cancer. FIT
only detects human blood from the lower intestines. FIT testing reduces the number
of patients having to undergo unnecessary invasive diagnostic testing and reduce the
waiting times for diagnosis of suspected cancer, as this test is initiated by the GP at
first appointment alongside any referral. The outcome of the FIT test ensures patients
are
in
the
seen
secondary care.
pathway
under
right
The Trust are also increasing capacity to diagnostic tests for the local population
through a planned Community Diagnostic Centre (CDC) which will provide additional
capacity in a community setting for patients in Tameside and Stockport. This is
additional capacity to the existing hospital sites and therefore will provide around
130,000 additional tests for the population. The centre will offer MR scans, CT scans,
Dexa scans, ECG, Phlebotomy and Spirometry and will be live in early 2024. The
CDC will focus on early testing for respiratory disease, cardiovascular disease, cancer,
and mental health issues and will help to ensure patients have access to these tests
sooner.
In addition, as part of the £16,000,000 Emergency Department redevelopment at the
Tameside Hospital site, additional scanning facilities are being included in the build to
ensure there is more capacity available at the hospital site in both the emergency
department setting and for planned diagnostics on elective and cancer pathways.
I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both
a national and regional level and helps us pay close attention to any emerging trends
that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
Medical Director for Professional Leadership and Clinical Effectiveness
NHS England
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