Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0135, written 12 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Mar 2024 |
|---|---|
| Reference | 2024-0135 |
| Deceased | Elizabeth Brown |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Manchester University 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, Senior Coroner, for the Coroner Area of Greater Manchester South 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 26th January 2023 I commenced an investigation into the death of Elizabeth Jane Brown .The investigation concluded on the 18th May 2023 and the conclusion was one of Narrative: Died from mesothelioma caused on the balance of probabilities by exposure to asbestos the precise source of which cannot be ascertained. The medical cause of death was 1a) Mesothelioma ; 2) Chronic Obstructive Pulmonary Disease 4 CIRCUMSTANCES OF THE DEATH Elizabeth Jane Brown had significant respiratory health issues including severe Chronic Obstructive Pulmonary Disease. In November 2022 a CT scan raised a suspicion of mesothelioma. Further tests and discussion confirmed that on the balance of probabilities she had mesothelioma caused by asbestos exposure. The source of the asbestos exposure could not be established. She deteriorated rapidly and died at Stepping Hill Hospital on 23rd January 2023 from mesothelioma. 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. 1 The MATTERS OF CONCERN are as follows. – The inquest heard evidence that Elizabeth Jane Brown had been referred to immunology services in 2018 due to low antibody levels and concerns about the overall impact on her health. A treatment plan was developed. She had an appointment on 4th February 2021 when the plan was that she should be followed up in 12 months’ time. She had not been seen again at the date of her death on 23rd January. Such long waits and delays to see immunologists in specialist clinics were the inquest was told not unusual notwithstanding the role they could play in treating those in need of immunology services. The evidence before the inquest was that the reason for those delays was a significant shortage of qualified /trained staff nationally which had led to services across the country being run with a high level of vacancies. The position was not improving in terms of recruiting to vacant posts the inquest was told 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 7th May 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 1) on behalf of the Family and; 2) Manchester University NHS Foundation Trust, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 2 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 12.03.2024 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
09 May 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Elizabeth Jane Brown
who died on 23 January 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12
March 2024 concerning the death of Elizabeth Jane Brown on 23 January 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Elizabeth’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about Elizabeth’s
care have been listened to and reflected upon.
Your Report raises the concern that there are long waits and delays to see
immunologists in specialist clinics and that these delays were caused by a significant
shortage of qualified/trained staff nationally which had led to services across the
country being run with a high level of vacancies.
Information received from the Immunology Specialty Advisory Committee at the Royal
College of Pathologists indicates that there are approximately 10-15 Immunology
Consultant vacancies across England at present, on a background of a reported
Consultant workforce of 89 whole-time equivalents (WTE) (data from December
2023). At higher level training posts, recruitment is very competitive, with 100% fill
rates for the last few rounds. There is a planned workforce distribution review, which
is intended to consider whether the posts need to be distributed differently, although it
is unlikely that there will be an increase as a result. NHS England have been informed
that The Royal College of Pathologists is planning to focus on workforce as one its key
priorities over the next few years, having already made written submissions to
Parliament in 2022.
The issue highlighted in this case appears to relate to follow up waiting times rather
than new outpatient waiting times and as such this would normally be for local
monitoring. However, the national Outpatient Transformation Team are exploring
ways to reduce long waiting times for patients who need monitoring by implementing
reviews of those on the waiting list for repeat appointments to which continue to be
clinically necessary. This work is planned for 2024/25.
NHS England is also working at a national level to deliver the Long-Term Workforce
Plan. This is a robust and effective strategy to ensure we have the right number of
people, with the right skills and support in place to be able to deliver the kind of care
people need. It heralds the start of the biggest recruitment drive in health service
history, but also of an ongoing programme of strategic workforce planning. It includes
ambitious commitments to grow the workforce by significantly expanding domestic
education, training, and recruitment, as well as actions aimed at improving culture,
leadership and wellbeing so that more staff are retained in NHS employment over the
next 15 years. These actions will aim to close anticipated staffing shortfalls in the NHS
in the long term, however Trusts have a responsibility to ensure safe staffing levels at
local level in the current day to day operation of their hospitals. This is in line with Care
Quality Commission (CQC) Regulation 18 which states that providers must deploy
enough suitably qualified, competent and experienced staff to enable them to meet all
other regulatory requirements.
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,
National Medical Director
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