Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0122, written 28 Feb 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Feb 2024 |
|---|---|
| Reference | 2024-0122 |
| Deceased | Kerri Mothersole |
| Coroner | Catherine Wood |
| Coroner area | Mid Kent and Medway |
| 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.
Mid Kent and Medway Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Date: 28 February 2024 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Kent and Medway Integrated Care Board 1. CORONER I am Catherine Wood, Assistant Coroner for Mid Kent and Medway 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. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 2 September 2022 I commenced an investigation into the death of Kerri Louise MOTHERSOLE. The investigation concluded at the end of the inquest . The conclusion of the inquest was: Narrative "She died as a consequence of endometrial cancer, the diagnosis of which was delayed due to a number of factors." 1a Endometrial Cancer with Brain Metastases 1b 1c II 4. CIRCUMSTANCES OF THE DEATH Kerri Mothersole was a 44 year old woman who had a past medical history of asthma, labyrinthitis, depression and back pain. In May 2020 she was seen with symptoms of possible early menopause and blood tests requested. In October 2020 she was noted to be suffering from tiredness and had irregular periods and again blood tests were requested. Blood tests taken in January 2021 noted a low haemoglobin and ferritin so iron was prescribed as well as follow up in 2 months. In March 2021 she complained of having per vaginal bleeding for 6 weeks and she was referred for an ultrasound. Due to her underlying ill health she had difficulty in attending appointments and missed a number of different appointments. She was seen in the surgery on 21 June 2021 by her General Practitioner who noted abdominal tenderness and weight loss and he again referred her for an ultrasound. An ultrasound was undertaken by a private firm HEM Clinical Ultrasound on 28 June 2021 but the report was never sent to her General Practitioner. A second ultrasound on the 1 July 2021suggested a diagnosis of adenomyosis but noting that serious pathology could not be ruled out. Only the second report was sent to the General Practitioner which led to a routine gynaecology referral, she had however already been referred to the colorectal team on the urgent two week wait pathway. Had the earlier scan report been seen this would have led to an urgent referral to gynaecology. There were a number of missed appointments and a colonoscopy took place on 20 October 2021. The procedure was negative but the endoscopist thought he could feel something in the pelvis and a CT scan was arranged. The CT scan on 28 October 2021 demonstrated a large pelvic mass and she was referred to the gynaecology team in early December and a multidisciplinary team meeting discussion on 17 December 2021 led to a request for an MRI scan. Appointments were made for 31 December 2021, 25 January 2022 and again in February but not attended and she eventually underwent an MRI on 1 May 2022 which revealed a large mass. She was again discussed at the multidisciplinary team meeting on 6 May 2022 and referred to the gynae-oncology surgeons at Maidstone hospital. She was seen on 1 June 2022 and booked for surgery on 27 June 2022. She was, however, far too unwell for surgery on 27 June 2022 and further investigations revealed brain metastases. She was admitted to hospital and treated with steroids and referred to the Oncologists as surgery was deemed no longer appropriate. She was prescribed hormone treatment but she was, by now, too unwell to receive even palliative radiotherapy. She was taken to Medway Maritime hospital on 19 August 2022 and was struggling as she had been so unwell at home. Whilst plans were being made to provide some care at home she remained overnight but sadly died on 20 August 2022 as she was so unwell she could not return home. 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. – (1) The two reports from HEM Clinical Ultrasound Ltd on 28 June 2021 and 1 July 2021 and any images associated with the reports were not provided to any of the deceased's treating clinicians. Only the second report from 1 July 2021 was sent to her General Practitioner and not the first report from 28 June 2021. Neither report was uploaded to her clinical notes at Medway Maritime hospital or Maidstone hospital. Had the images and the reports been available to her treating clinicians then a more urgent referral would have been warranted by her General Practitioner and she may have been investigated and treated at a much earlier stage. (2)The court heard that most of Kent have a system whereby imaging taken can be seen at more than one Trust and is even linked to tertiary referral centres in London. The system used was referred to as the PACS system. Clinicians told the court that they could look up images for their patients taken at another hospital and this would impact on their decision making for a patient. Images taken in the community by private providers are not uploaded to the system but can be requested however this relies upon knowing that there were any images to access in the first instance. (3) The managing partner at HEM Clinical Ultrasound Ltd gave evidence that she had been requesting that the imaging they took be made available on the central system. She was unable to explain why this had not been requested or set up or commissioned by the Integrated Care Board. All gave evidence that the lack of imaging being available meant that issues could be missed and this created a risk to patients, which at its extreme would include a risk of future deaths. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you the Integrated Care Board 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 30 April 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 Kerri Mothersole's son and her partner, Medway Maritime NHS Trust, Maidstone and Tunbridge Wells NHS Trust, HEM Clinical Ultrasound Ltd and Green Porch Medical Centre. 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. 5 March 2024 Signature Catherine Wood Assistant Coroner for Mid Kent and Medway
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.
The Office of the Chief Executive 2nd Floor Gail House Lower Stone Street Maidstone ME15 6NB Private and confidential Central and South East Kent Coroners Oakwood House Oakwood Park Maidstone Kent ME16 8AE Tuesday 30th April 2024 Dear Ms Wood, NHS Kent and Medway Regulation 28 Response re Kerri Louise Mothersole Thank you for your Prevention of Future Deaths Report dated 28 February 2024 sent pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 concerning the death of Ms Kerri Louise Mothersole on 20 August 2022. I understand that during the course of the inquest you heard evidence that you felt needed to be addressed by the Integrated Care Board (ICB) to prevent future deaths. I will address your concerns, which are as follows: (1) The two reports from HEM Clinical Ultrasound Ltd on 28 June 2021 and 1 July 2021 and any images associated with the reports were not provided to any of the deceased's treating clinicians. Only the second report from 1 July 2021 was sent to her General Practitioner and not the first report from 28 June 2021. Neither report was uploaded to her clinical notes at Medway Maritime hospital or Maidstone hospital. Had the images and the reports been available to her treating clinicians then a more urgent referral would have been warranted by her General Practitioner and she may have been investigated and treated at a much earlier stage. (2)The court heard that most of Kent have a system whereby imaging taken can be seen at more than one Trust and is even linked to tertiary referral centres in London. The system used was referred to as the PACS system. Clinicians told the court that they could look up images for their patients taken at another hospital and this would Ref: 41799682 impact on their decision making for a patient. Images taken in the community by private providers are not uploaded to the system but can be requested however this relies upon knowing that there were any images to access in the first instance. (3) The managing partner at HEM Clinical Ultrasound Ltd gave evidence that she had been requesting that the imaging they took be made available on the central system. She was unable to explain why this had not been requested or set up or commissioned by the Integrated Care Board. All gave evidence that the lack of imaging being available meant that issues could be missed and this created a risk to patients, which at its extreme would include a risk of future deaths. As all three of the concerns that you have highlighted in the Regulation 28 Report appear to relate to the same issue, i.e., the inability to upload images to the Picture Archiving System (PACS) system by private providers in Kent and Medway, I will respond to all concerns together. While the ICB accepts that this is the case, it is normal practice across the NHS in England for community ultrasound services not to be directly connected to any Integrated Care System PACS solution. For information regarding this patient’s case, the ICB Patient Safety Team has requested that HEM Clinical Ultrasound complete a Serious Incident (SI) Investigation regarding the Coroner’s first concern. This concern notes that there were two ultrasound reports available, only one of which was initially sent to the patient’s GP. The provider has stated that that first report was inaccurate and should not have been sent to the patient’s GP. To address the concerns highlighted in the Regulation 28 Report, we can confirm that Kent and Medway have been moving away from individual PACS systems resident in each of our providers to a central PACS system. Procurement commenced in 2021, with the integration of acute provider trusts in September 2023. Community diagnostics were introduced in the 2010s to improve access and reduce cost. However, no work was commissioned at the time to provide integration to GP or acute systems. The standard protocol is for community diagnostic providers to send reports (text-based), as opposed to the full diagnostics image, back to the GP that requested the investigation. The GP will then assess the report in the context of their holistic assessment of the patient and they make a clinical decision on whether to refer a patient to secondary care. Notwithstanding the above, NHS Kent and Medway have taken the following actions to reduce the risk of the scenario in the coroner’s report happening again in the future: 1. The ICB’s Contracting Team issued a contract variation (CV) letter on 10 April 2024 to all existing community Any Qualified Providers (AQPs) that provide direct access diagnostic services for patients in the network. All community AQPs will be required to telephone the patients’ registered GP within 5 days of any suspicious or incidental clinical findings noted on a diagnostic imaging report that the GP has a responsibility to act upon urgently. All community providers will be required to keep a log of the date the telephone call was made Page 2 of 3 Ref: 41799682 to the patients’ GP practice and the contact details of the patients GP liaised with for both audit and patient safety purposes. This process is already in place with providers and GPs where suspicious pathological findings have been identified. The ICB’s Contracting Team have requested all community diagnostic providers return the signed (CV) letter by 30 April 2024. NHS Kent & Medway’s Primary Care Team have also issued out communications to all member GP practices on 11 April 2024, advising them of the new process in place. This will continue to be monitored via monthly ICB Primary Care Board and Contract Monitoring meetings. 2. To provide longer term assurance, and in acknowledgment of this matter, NHS Kent and Medway will examine potential changes where appropriate relating to IT integration. To support this, we will undertake a review of how the incident occurred and determine how the risk of this re-occurring can be reduced. This will include: a. Mapping processes in the diagnostic imaging workflow, including manual and automated processes, highlighting where processes failed. b. Auditing key systems that are used to understand how patient diagnostic data is flowed and shared through the end-to-end diagnostic process highlighting where there are issues. c. Creating an options appraisal, identifying opportunities for improvements in process, and integrations of systems including estimated costs and timescales. d. Considering the Options Appraisal and the feasibility of any recommendations. It is anticipated that the production of an Options Appraisal will be delivered by the end of August 2024. Based on the above, I hope I have provided you with the relevant assurance that Kent and Medway ICB has taken your concerns seriously and that we will continue to strive to provide an appropriate range of services to people undergoing imaging in the community by private providers, and to offer high standards of care to our patients. Yours sincerely Chief Executive NHS Kent and Medway Page 3 of 3
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