Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0180, written 2 Apr 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Apr 2024 |
|---|---|
| Reference | 2024-0180 |
| Deceased | Alan Soane |
| Coroner | Ian Potter |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report Alan Andrew SOANE (died 26 June 2023) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. NHS England 133-135 Waterloo Road London SE1 8UG 2. The Rt Hon Victoria Atkins MP Secretary of State for Health and Social Care 39 Victoria Street London SW1H 0EU 1 CORONER I am Ian Potter, assistant coroner, for the coroner area of Inner North London. 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 30 June 2023, an investigation was commenced into the death of ALAN ANDREW SOANE, then aged 84 years. The investigation concluded at the end of an inquest, heard by me, on 18 March 2024. The inquest concluded with a short narrative conclusion. The medical cause of death was: 1a intra abdominal sepsis and haemorrhagic shock 1b anastomotic leak following pancreatico-duodenectomy (performed 05/06/2023). 4 CIRCUMSTANCES OF DEATH Mr Soane was an otherwise fit and healthy 84 year old man. The circumstances of his death are recorded in the short narrative conclusion that I reached at the inquest, which was: “Mr Soane underwent an endoscopy and biopsies at his local hospital in Essex in March 2023, which included a duodenal biopsy. The result of the duodenal biopsy was reported as, ‘Findings are highly suspicious for malignancy, most likely differentiated adenocarcinoma. Immunohistochemical study is requested, and a supplementary report will follow.’ As a result, Mr Soane was referred to the Royal London Hospital on a cancer pathway. A multidisciplinary team (MDT) meeting at the Royal London Hospital on 3 May 2023, concluded, among other things, ‘diagnosis: duodenal cancer (biopsy- proven).’ That meeting was undertaken without further biopsy or tests being undertaken. It transpires that the conclusion was not correct. Based on the outcome of the MDT meeting, Mr Soane was given a cancer diagnosis and agreed to complex surgery known as a ‘Whipples’ procedure, which was undertaken on 5 June 2023. Mr Soane died on 26 June 2023, as a direct result of known complications of the Whipples procedure. Mr Soane’s surgeon would not have offered him the Whipples surgery had it not been for the incorrect diagnosis provided.” 5 CORONER’S CONCERN During the course of the inquest the evidence 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 MATTER OF CONCERN is as follows:- (1) The NHS Trust in this case was, and remains, unable to provide for the presence of a Consultant Histopathologist at Hepato-pancreato- biliary MDT meetings. It was acknowledged that this was a factor that led to Mr Soane being given a cancer diagnosis that was incorrect. This inability to provide a Consultant Histopathologist is something that has been on the Trust’s risk register for over five years and recruitment exercises have taken place, to no avail. I was told in evidence that this is attributed to the fact that nationally, 25% of Consultant Histopathologist roles remain vacant; in short, there is a national shortage of Consultant Histopathologists. The concern here is that a national shortage of Consultant Histopathologists puts a widespread proportion of the patient population at a significant risk. I was reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified, by attempting to recruit to the vacant post. However, I was not reassured that action has been taken at a national level to address the shortage generally. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that 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 the report, namely by 28 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: (a) (b) (Mr Soane’s wife) , Chief Executive, Royal College of Pathologists, 6 Alie Street, London, E1 8QT 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 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 Ian Potter HM Assistant Coroner, Inner North London 2 April 2024
2 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.
Mr Ian Potter St Pancras Coroner’s Court Camley Street London N1C 4PP Dear Mr Potter, 24 May 2024 Thank you for your Regulation 28 report to prevent future deaths dated 2 April about the death of Mr Alan Andrew Soane. I am replying as Minister with responsibility for major diseases, including cancer. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Soane’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over the NHS Trust’s inability to provide for the presence of a Consultant Histopathologist at Hepato-pancreato-biliary multi-disciplinary team meetings, and over the number of vacant Consultant Histopathologist roles nationally. In preparing this response, Departmental officials have made enquiries with NHS England (NHSE). I have been informed that NHSE has been granted an extension to 18 June to send a response to you. As an Executive Agency of the Department of Health and Social Care, NHSE’s response should further address the concern you raised. I would like to reassure you that the training and recruiting of medical professionals is a very important matter for the government. I share your concern, and I would like to explain what the government is doing to address this. As of January 2024, there are 1,276 full-time equivalent (FTE) Consultant doctors working in the specialty of histopathology within NHS trusts and other core organisations in England. This is 16 (1.2%) more than in January 2023, 70 (5.8%) more than in January 2019 and 188 (17.3%) more than in January 2010. In addition, GMC data shows that in 2023 there were 506 doctors in histopathology specialty training in England, which is 38 (8.1%) more than in 2022 and 123 (32.1%) more than in 2019. 1 From the Rt Hon Andrew Stephenson CBE MP Minister of State for Health and Secondary Care 39 Victoria Street London SW1H 0EU The NHS Long Term Workforce Plan (LTWP), published by NHS England in June 2023, sets out the steps the NHS and its partners need to take to deliver an NHS workforce that meets the changing needs of the population over the next 15 years. The plan outlines the action needed to ensure we train and retain more staff, and reform medical education and training to put the NHS workforce on a sustainable footing for the future. The LTWP sets out the aim to double the number of medical school places in England to 15,000 places a year by 2031/32, and to work towards this expansion by increasing places by a third, to 10,000 a year, by 2028/29. We have brought forward the trajectory of this planned expansion for the last 2 years, having allocated 205 and 350 additional places for the 2024/25 academic years respectively. There are now an additional 1,500 medical school places per year for domestic students in England – a 25% increase, taking the total number of medical school places in England to 7,500 each year. These expansions will increase the pool from which future histopathologists and other specialists can be drawn. The department will continue to work with NHS England and other system partners to deliver the ambitions set out in the LTWP to ensure improvements for patient safety and outcomes. I hope this response is helpful. Thank you for bringing this concern to my attention. THE RT HON ANDREW STEPHENSON CBE MP MINISTER OF STATE
Ian Potter
Assistant Coroner
Inner North London
St Pancras Coroners Court
Camley Street
London
N1C 4PP
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
18 June 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Alan Andrew Soane who
died on 26 June 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 April
2024 concerning the death of Alan Andrew Soane on 26 June 2023. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to Alan’s family and loved ones. NHS England are keen to assure
the family and the coroner that the concerns raised about Alan’s care have been
listened to and reflected upon.
I am grateful for the further time granted to respond to your Report and I apologise for
any anguish this delay may have caused to Alan’s family or friends. I realise that
responses to Coroner Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones and appreciate
this will have been an incredibly difficult time for them.
Your Report raised concerns that there is a national shortage of Consultant
Histopathologists and that this puts a widespread proportion of the patient population
at significant risk.
NHS England is 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 in the
current day to day operation of their hospitals. This is part of the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 2018 (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.
The Long-Term Workforce Plan also outlines how NHS England will need to take full
advantage of digital and technological innovations. This includes using AI diagnostic
support to improve accuracy and efficiency of diagnostics in services that include
pathology. Investment and support into pathology and imaging networks is ongoing
and is expected to increase productivity across imaging and pathology services by up
to 10% by March 2025.
Since January 2010, there has been a 17% increase to 1,276 in the full-time equivalent
of consultant doctors working in the specialty of histopathology within NHS
organisations. Data from the General Medical Council also shows that in 2023 there
were 506 doctors in histopathology speciality training in England, which is a 32%
increase since 2019.
My colleagues within the London region are also engaging with North East London
Integrated Care Board to ascertain more details about Alan’s care and to gain
assurance that learnings have been taken regarding Alan’s incorrect diagnosis and
treatment.
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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