Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0292, written 29 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 May 2024 |
|---|---|
| Reference | 2024-0292 |
| Deceased | George Broadhurst |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1) NHS England 1 CORONER I am Alison Mutch, 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 12th October 2023 I commenced an investigation into the death of George Barry Broadhurst. The investigation concluded on the 30th April 2024 and the conclusion was one of Narrative: Died from the complications of a fracture sustained in an accidental fall where the fracture was not recognised immediately. The medical cause of death was 1a) Pulmonary Embolism and Community Associated Pneumonia 1b) Infected traumatic thoracic vertebral fracture 1c) Fall. 4 CIRCUMSTANCES OF THE DEATH George Barry Broadhurst lived independently and was mobile. Around the 4th September 2023 he had an accidental fall at his home address. He reported to his GP that he had injured his lower back and was in pain. He was advised to attend A&E but declined. He managed with pain relief at home. He continued to manage at home until 25th September 2023 when he went to Tameside General Hospital. An x-ray was taken. He was discharged. The x-ray showed a fracture of the vertebrae but this was not identified at that time. A radiologist reported on the x-ray 2 days later and it was to be reviewed by a Consultant but was not done due to backlogs. On 1st October 2023 he went to Stepping Hill Hospital with worsening back pain. The fracture was identified and he was discharged home with pain relief and treatment for a lower respiratory tract infection and with support in the community. At home he deteriorated rapidly. He was readmitted on 7th October to Stepping Hill Hospital. He had a collapsed 1 lung, pulmonary embolism and an infected fractured vertebra. The collapsed lung and pulmonary embolism were as a consequence of lack of mobility due to the fracture. He deteriorated and died at Stepping Hill Hospital on 10th October 2023. 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 inquest heard evidence that the delay in reporting of X rays by radiologists is not unique to Tameside but is a national picture caused by a shortage of radiologists and trained reporting radiographers. The impact of the shortage is that ED doctors are interpreting x rays in highly pressured situations without specialist input and with a consequential risk of missing more subtle fractures. This means that patients are discharged with fractures rather than appropriate treatment or conversely are given unnecessary treatment that then has to be reversed once a specialist review takes place. 2. The knock-on impact of the delay in reporting is that once the radiology reports are available they then have to be reviewed in conjunction with the notes by a consultant days after the attendance to ensure the treatment given fits with the reported findings. This is a significantly more time-consuming process than them being looked at in real time and results in ED consultant resource being diverted away from the day to day demands of ED. Thus, placing a greater strain on clinicians in ED and stretching resources more thinly. 3. The evidence given was that the level of pain that Mr Broadhurst still had in the community after 1st October was not in keeping with a healing fracture. The inquest was told that it was important that community/primary care teams were trained to understand how “normal” pain, in the context of a fracture being managed in the community, would present and what was a red flag/ deteriorating situation. Training on expectations around healing fractures would ensure what was a life-threatening deterioration was picked up and escalated at the earliest possible point. 2 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 24th July 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; 2) Weightmans LLP on behalf of Tameside General Hospital and; 3) Browne Jacobson LLP on behalf of Stepping Hill Hospital, who may find it useful or of interest. 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 29.05.2024 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.
Ms Alison Mutch
HM Senior Coroner
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
24/07/2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – George Barry Broadhurst
who died on 10 October 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 May
2024 concerning the death of George Barry Broadhurst on 10 October 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to George’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about George’s
care have been listened to and reflected upon.
Your Report raised concerns over a national shortage of radiologists and trained
reporting radiographers, and the consequential risk of Emergency Department (ED)
doctors interpreting X-rays without specialist input and discharging patients with more
subtle fractures, as well as the impact delayed reporting of X-ray results has on ED
consultant resource.
Following additional investment through spending review settlements in 2021/22 and
2022/23, the NHS has observed a significant and sustained expansion in recruitment
to specialty training places. Clinical Radiology recruitment increased from an average
of 234 trainees per year (between 2016 and 2020), to an average of 328 (between
2021 and 2022), meaning an expansion of around 100 specialty trainee places per
year.
The current spending review settlement has enabled continued expansion of Clinical
Radiology training places at similar levels, with planned expansion of places totalling
110 in 2022/23, 100 in 2023/24, and 75 in 2024/25. Continued expansion, through
2025 and beyond, will form part of Long Term Workforce Plan and spending review
discussions.
A programme of international recruitment also ran in 2023/24 to enable Community
Diagnostic Centres (CDCs) to deliver diagnostics and achieve the benefits in access,
recovery and transformation of care. During 2023/24, 21 Radiologists were appointed
through the programme. Further international recruitment is planned for 2024/25, with
demand planning currently underway.
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 NHS Trusts have a responsibility to ensure safe staffing
levels in the current day to day operation of their hospitals. This is in line with 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.
Accident & Emergency (A&E) departments are required to have local procedures in
place to ensure that they follow up X-ray reports, based on the formal report being
finalised, as pathologies can be missed via A&E routes and imaging services do not
support/deliver 24/7 reporting services for general X-rays.
On behalf of the Royal College of Radiologists, the Academy of Medical Royal
Colleges (AMRoC) published ‘Alerts and notification of imaging reports’ in October
2022, which makes clear that the referrer is required to act on the report issued by
imaging, and that it is the responsibility of the requesting doctor and/or their clinical
team to read and act upon the report findings and fail-safe alerts as quickly and
efficiently as possible. This extends to ensuring robust mechanisms are in place and
that there are suitable resources to cover leave within clinical teams or practices.
Your Report also raised concerns over community / primary care teams recognising
red flag / deterioration symptoms and pain within the context of a fracture, and the
importance of training for this. NHS England’s Primary Care colleagues have reviewed
your Report and have advised that there is existing National Institute for Health and
Care Excellence (NICE) guidance for primary care healthcare professionals on the
assessment and management of back pain. This includes guidance on asking about
red flag symptoms and the list of red flag symptoms.
I would also like to provide further assurances on the 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 to 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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