Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0537, written 20 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 | 20 Dec 2023 |
|---|---|
| Reference | 2023-0537 |
| Deceased | Gregor Lynn |
| Coroner | Caroline Jones |
| Coroner area | Cambridgeshire and Peterborough |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1. Department of Health and Social Care 2. Cambridgeshire & Peterborough Integrated Care System 3. NHS England 1 CORONER I am Caroline Jones, Assistant Coroner for the coroner area of Cambridgeshire & Peterborough. 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 29 July 2022, I commenced an investigation into the death of Gregor Patrick Edward Lynn aged 24 years. The investigation concluded at the end of the inquest on 30 August 2023. The conclusion of the inquest was that: Gregor died of natural causes due to a disseminated metastatic melanoma He had developed a lesion on the back of his neck in March 2019 which was excised privately but the excised material was not sent for histological analysis, likely due to the additional cost associated with having to have the samples analysed privately By the time the lesion recurred in May 2020 and was examined under the urgent care dermatology pathway, it was found to be a melanoma which had metastasised and was beyond effective treatment. 4 CIRCUMSTANCES OF THE DEATH In March 2019, the consequence of Gregor not meeting the referral criteria for NHS treatment upon initial presentation with a nuisance lesion to the back of his neck was that he had to self-refer for private treatment at a reported cost of c.£140. He was advised that the additional cost of histological analysis of the excised samples would be c.£65 and so decided not to have the samples sent for analysis. When the lesion continued to trouble him in May 2020, he returned to his GP who referred him to dermatology, where a further excision was performed and analysed and was found to be melanoma. An ultrasound scan showed that the melanoma had metastisised to his lymph nodes, chest wall and lungs. Despite immunotherapy and targeted oral therapy, the melanoma continued to metastasise and in June 2022, scans showed that it had spread to Gregor’s brain such that his condition was terminal. He was placed onto a palliative care pathway and following an admission to Addenbrooke’s hospital on 6 July 2022, he died on 8 July 2022. 5 Regulation 28 – After Inquest Document Template Updated 30/07/2021 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: I was not able to conclude that, had the sample been sent for analysis in March 2019, any sign of melanoma would have been detected. Nevertheless, it is of concern that the barrier to undergoing a complete procedure, including histological analysis, appears to be one of cost. Anecdotal evidence received at inquest from treating clinicians was that the further costs associated with histological or other review, which on the NHS would be routinely included within the procedure at no charge to the patient, was a common disincentive to patients who would regularly opt not to have the further tests carried out. While it is acknowledged that there have to be criteria for routine and non-emergency procedures to be conducted on the NHS, my concern relates to the disparity in what is included within the treatment when undertaken privately (where histological analysis is a separate and additional cost) and what is routinely included as part of NHS treatment It therefore seems to me that there is a risk of future deaths if patients not meeting the NHS referral criteria, who have to pay for procedures to be carried out privately, opt on cost grounds not to have the histological analysis which would otherwise be provided on the NHS at no charge, as it is well-established fact that earlier detection and treatment is crucial in minimising the risks of developing metastatic cancers including melanoma. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 February 14, 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: 1. Family of Gregor Lynn 2. GP as well as the other recipients identified at the top of the report. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 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 Dated: 20/12/2023 Caroline JONES Assistant Coroner for Cambridgeshire and Peterborough Regulation 28 – After Inquest Document Template Updated 30/07/2021
3 responses 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.
Our Ref: CC007
Date:
5 February 2024
Caroline Jones
Assistant Coroner
Coroner’s Office
Cambridgeshire & Peterborough Coroner's Service
Lawrence Court
Princes Street
Huntingdon
PE29 3PA
Response to be sent via email
Coroners@cambridgeshire.gov.uk
anna.page@cambridgeshire.gov.uk
Caroline.Jones@cambridgeshire.gov.uk
Dear Ms Jones
Re: Regulation 28 Report to Prevent Future Deaths – Gregor Patrick Edward Lynn
Thank you for your Regulation 28 Report dated 18th December 2023 concerning the death of Gregor Patrick
Edward Lynn who died on 8th July 2022.
Firstly, we would like to express our sincere condolences to the family. We have taken this matter extremely
seriously.
The Regulation 28 Report concludes that Mr Lynn’s death resulted from disseminated metastatic
melanoma. Following the inquest you raised concerns in your Regulation 28 Report that patients who have
lesions excised privately do not always have the histological analysis which would be provided on the NHS
as standard practice in primary care.
Unfortunately, NHS Cambridgeshire and Peterborough Integrated Care Board has no influence over the
pricing structure, or the optionality of histology, offered by private providers that deliver non-NHS funded
treatment within our geographical area.
However, to ensure that we do all we can to learn from Mr Lynn’s death and improve care for future patients
we have used the information you provided to consider other related safety aspects.
We understand from the Prevention of Future Death Notice that the lesion when initially reviewed in 2019
was considered benign, so we have reviewed both our current referral policies for benign skin lesions and
our previous version that was in place at the time.
6
Our current benign skin lesion policy states that whenever there is diagnostic uncertainty or there is
suspicion of malignancy the benign skin policy should not be used as the patient should be referred onto
the relevant NHS provider.
As a result of receiving your Regulation 28 Notice we are taking the following actions:
• Signposting all GPs working for the NHS within NHS Cambridgeshire and Peterborough Integrated
Care System to guidance on detection of skin cancers.
• Reminding all the GPs working for the NHS within NHS Cambridgeshire and Peterborough
Integrated Care System that for any skin lesions where there is diagnostic uncertainty, or if there
are concerns of malignancy, appropriate onward referral should occur and the benign skin policy
should not be used.
• Reminding all services that we commission in primary care that when any skin lesions are excised
in primary care they should be sent routinely for histology.
Thank you for bringing this important patient safety issue to our attention. Please do not hesitate to contact
us should you need any further information.
Yours sincerely,
Dr Fiona Head
MA FRCP MRCGP FFPH DTM&H
Chief Medical Officer
7
The Rt Hon. Andrew Stephenson CBE MP Minister of State for Health 39 Victoria Street London SW1H 0EU HM coroner Caroline Jones Coroner’s Service Lawrence Court Princes Street Huntingdon PE29 3PA 16 April 2024 Dear Caroline, Thank you for your letter of 20 December 2023 about the death of Mr Gregor Lynn. I am replying as the Minister with responsibility for Health. Firstly, I would like to say how very saddened I was to read of the circumstances of Mr Lynn’s death, and I offer my sincere condolences to his family and loved ones. The issues that your report highlights are very concerning, and I am grateful to you for bringing them to my attention. In preparing this response, Departmental officials have made enquiries with NHS England (NHSE) and have been informed that Professor Sir Stephen Powis, the National Medical Director for NHSE, responded to you in detail about the serious issues raised in your report. ’ response addresses some of your concerns. Professor I do hope that Powis highlights existing clinical guidelines produced by the National Institute for Health and Care Excellence (NICE) relating to the identification of people with symptoms that could be caused by cancer, and appropriate investigations within primary care settings. NICE has also issued a document specifically relating to referral for suspected skin cancer. also notes that NHSE has raised your concerns directly with the Integrated Care System (ICS) relevant to this case (Cambridgeshire and Peterborough), who have reviewed their policy for benign skin lesions and updated GPs about this while reminding them of existing national guidance relating to suspected skin cancer. With regard to your concern about charging for additional activities by independent sector providers, it is reasonable that they should be able to charge for services which are not provided under contracts with the NHS. Ultimately, it is for independent sector 4 providers to design services and corresponding fees for self-funding patients. However, I would like to reiterate that the safety of all patients, irrespective of whether they are treated in the NHS or the independent sector, is a top priority for the government. Patients who opt to self-fund their care also retain their right to access NHS care. All providers of healthcare are regulated by the Care Quality Commission and follow a set of fundamental standards of safety and quality, below which care should never fall. In addition, doctors in the UK are regulated by the General Medical Council (GMC), who are responsible for ensuring that medical professionals have the necessary skills and knowledge to join the medical register. All doctors must register with the GMC, hold a licence to practice, and meet the regulator’s expected standards, including the ‘Good medical practice’ standards, which states that doctors “must provide a good standard of practice and care… (and) refer a patient to suitably qualified practitioner when this serves their needs.” There are also existing routes to raise concerns regarding the professional conduct or behaviour or individual doctors through the GMC - Concerns about doctors - GMC (gmc-uk.org). I hope this response is helpful. Thank you for bringing these concerns to my attention. THE RT HON ANDREW STEPHENSON CBE MP MINISTER OF STATE 5
Caroline Jones
Cambridgeshire and Peterborough
Coroner’s Service
Lawrence Court
Princes Street
Huntingdon
PE9 3PA
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
13 February 2024
Re: Regulation 28 Report to Prevent Future Deaths – Gregor Patrick Edward
Lynn who died on 8 July 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20
December 2023 concerning the death of Gregor Patrick Edward Lynn on 8 July 2022.
In advance of responding to the specific concerns raised in your Report, I would like
to express my deep condolences to Gregor’s family and loved ones. NHS England are
keen to assure the family and the coroner that the concerns raised about Gregor’s
care have been listened to and reflected upon.
Your Report raised the concern that there is a risk of future deaths if patients opt out
of paying for histological analysis or further tests when being treated privately because
they have not met NHS criteria referral.
As you have outlined in your Report, the GP who undertook the excision in this case
was doing so on a private patient basis. NHS England and NHS commissioners are
not able to influence how private care is delivered to patients. I note that you have also
sent your Report to the Department of Health and Social Care. You may also wish to
refer this case to the Care Quality Commission (CQC) who are responsible for
ensuring that standards of quality and safety are upheld within private hospitals and
clinics.
Regarding the initial management of an evolving, changing lesion within a primary
care setting, the National Institute for Health and Care Excellence (NICE) guidelines
for Suspected cancer: recognition and referral (NG12) cover the identification of
children, young people and adults with symptoms that could be caused by cancer and
the appropriate investigations within primary care settings. Cancer Specialists at NHS
England have been consulted on this case and have advised that it would have been
reasonable for an NHS referral to be made in this case, given the size of the lesion
and the apparently irregular features and that any changing lesion, where a definitive
diagnosis has not been made, should be considered for a referral to secondary care.
NICE issued a document titled ‘Scenario: ‘Referral for suspected skin cancer’, first
published in 2000, and subject to a minor update in 2016, which states:
8
"Discussion with a specialist (for example, by telephone or email) should be
considered if there is uncertainty about the interpretation of symptoms and signs, and
whether a referral is needed. This may also enable the primary healthcare professional
to communicate their concerns and a sense of urgency to secondary healthcare
professionals when symptoms are not classical."
on
the
The Academy of the Medical Royal Colleges (AoMRC) have also a produced a
lesions:
document
https://ebi.aomrc.org.uk/interventions/removal-of-benign-skin-lesions/. This states
that ‘Any lesion where there is diagnostic uncertainty, pre-malignant lesions (actinic
keratoses, Bowen disease) or lesions with pre-malignant potential should be referred
or, where appropriate, treated in primary care.'
optimum management
benign
skin
of
In addition, NHS England notes from the GP statement given to the coroner inquiry
the additional information that the lesion had been noted to bleed. Thus, it would
appear to meet the criteria for NHS referral to a dermatologist.
As stated above, NHS England is not able to comment on the care provided to Gregor
within a private health setting. However, the standard of care for any changing lesion
would, in most cases, be to get histological confirmation of its nature and this should
have been recommended to the patient. We note from the GP’s statement that they
state they would have done so.
NHS England have also engaged with Cambridgeshire and Peterborough Integrated
Care System (ICS), formerly the Clinical Commissioning Group (CCG) in this matter,
on the concerns raised in your Report and any system and local learnings that have
been taken. They have advised that they have reviewed their policy for benign skin
lesions which states that if there is any diagnostic uncertainty as to whether a lesion
is benign, or any possibility that it could be malignant, the policy should not be used,
and an appropriate referral made.
The ICS have advised that they have:
• Reminded all GPs within Cambridgeshire and Peterborough Integrated
Care System of the guidance on skin cancers.
• Shared the benign skin lesion policy to the GPs within Cambridgeshire and
Peterborough Integrated Care System such that clinicians are cognisant
that in all cases of diagnostic uncertainty or if there are concerns of
malignancy onward referral should occur.
• Reminded their NHS primary care commissioned dermatology services of
the guidance on techniques and facilities for conducting minor surgery and
relevant best practise guidance, including that all tissue removed by minor
surgery should be sent routinely for histological examination unless there
are exceptional reasons for not doing so.
Initiated discussions with the British Association of Dermatology and NHS
England colleagues to ensure that there is learning and exploration of
national management guidance which includes skin cancer.
•
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
9
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,
National Medical Director
10
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