Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0301, written 26 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jan 2024 |
|---|---|
| Reference | 2024-0301 |
| Deceased | Paul Bradley |
| Coroner | David Reid |
| Coroner area | Worcestershire |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Worcestershire Acute Hospitals NHS 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 THIS REPORT IS BEING SENT TO: 1) , Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD 1 CORONER I am David Donald William REID, HM Senior Coroner for Worcestershire. 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 18 May 2023 I commenced an investigation and opened an inquest into the death of Paul William BRADLEY. The investigation concluded at the end of the inquest on 18 January 2024 The conclusion of the inquest was that Mr. Bradley “died from natural causes.” 4 CIRCUMSTANCES OF THE DEATH In answer to the questions “when, where and how did Mr. Bradley come by his death?”, I recorded as follows: “In July 2019 Paul Bradley was diagnosed with renal cancer. Over the next two years his renal tumour was monitored, and by February 2021 it was felt that he should now be considered for a nephrectomy. When he failed to attend a urological appointment in March 2021, this was not followed up by the urology team and no further appointment was arranged until he was referred again by his general practitioner in May 2023, after a CT scan had shown a metastatic renal tumour. He was admitted to the Alexandra Hospital, Redditch for palliative treatment and declined and died there on 17.5.23. The failure to try to arrange a further urological appointment after March 2021 represents a missed opportunity to provide Mr. Bradley with treatment which may have prolonged his life.” 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. – In the course of the inquest, I found the following facts to have been established: 1) Although Mr. Bradley had already been documented to have been hard of hearing, the urological appointment he was offered in March 2021 was by telephone, and he had not confirmed prior to that appointment that he would be willing and able to attend it. It is quite possible that he did not hear the telephone when attempts were made to contact him. It was conceded at 1 inquest by investigation on behalf of the Trust, that it was a mistake to have tried to arrange this appointment by telephone, and that it should have been conducted in person; , who conducted a serious incident 2) After the urology appointment in March 2021 was missed, there is no evidence that letters seeking to rearrange it were sent either to Mr. Bradley or to his GP. In his evidence at the inquest, “[ the Trust’s ] tracking system should have picked up on the fact that Mr. Bradley’s treatment targets had not been met”; and “the urology team’s system for tracking cancer patients needs to be improved...” but that “[ there is ] still some disagreement as to how this should be done”. stated: 3) Between March 2021 and December 2022, despite receiving no follow up from the urology team, Mr. Bradley continued to have appointments with Prof. Downing’s vascular team, to whom he had been referred because of a potential weakness in his aorta, which may have affected the decision to proceed with a nephrectomy. He did not, however, attend for PET scan appointments in the summer of 2021 which the vascular team had organised. There is no evidence that the vascular team wrote to Mr. Bradley or to his GP about those missed scan appointments; 4) Despite contact with the vascular team relating directly to his urological issues, there is no evidence that either team contacted the other about Mr. Bradley’s missed appointments; nor did the vascular team update the urology team about the appointments which Mr. Bradley did attend. In his evidence at the inquest, “I think the vascular team should have been keeping the urology team abreast of their contacts with Mr. Bradley. I think maybe they lost focus of the bigger picture, i.e. that these vascular investigations were being done because of the potential renal surgery.” stated: I was therefore satisfied that: (a) The Trust’s urology team had no clear system in place to try to ensure that a patient who missed an important urology appointment could be followed up, and his treatment targets met. That still appears to be the case; (b) Where, as here, more than one team was involved in a patient’s care, there was no clear system in place to ensure that the teams involved communicated with each other about the progress they were making with the patient, and about any appointments missed by the patient. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executive of Worcestershire Acute Hospitals Trust, 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 22 March 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: 2 (a) ( Mr. Bradley’s brother ). 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 26 January 2024 David REID HM Senior Coroner for Worcestershire 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.
Office of the Managing Director 22 March 2024 Mr D D W Reid HM Senior Coroner Worcestershire Coroners Court Martins Way Stourport on Severn Worcestershire DY13 8UN Dear Mr Reid Re: Paul William Bradley deceased Regulation 28 Report to Prevent Future Deaths Please accept this letter in response to your Regulation 28 Report to Prevent Future Deaths sent on 29th January 2024, following the Inquest touching on the death of Mr Paul Bradley. In your Regulation 28 report you identified the following matters of concern relating to the Worcestershire Acute Hospitals NHS Trust (WAHT) 1) It was a mistake to have tried to arrange this appointment by telephone, and that it should have been conducted in person. 2) After the Urology appointment in March 2021 was missed, there is no evidence that letters seeking to rearrange it were sent to either Mr Bradley or to his GP 3) There is no evidence that the vascular team wrote to Mr Bradley or to his GP about those missed scan appointments. 4) There is no evidence that either team contacted the other about Mr Bradley’s missed appointments; nor did the vascular team update the urology team about the appointments which Mr Bradley did not attend. I was therefore satisfied that: a) The Trust’s Urology team had no clear system in place to try to ensure that a patient who missed an important urology appointment could be followed up, and his treatment targets met. b) Where, as here, more than one team was involved in a patient’s care, there was no clear system in place to ensure that the teams involved communicated with each other about the progress they were making with the patient, and about any appointments missed by the patient Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD Office of the Managing Director Responding to the concerns raised: A significant amount of work has been undertaken by the Trust Patient Experience team over the past 12 months, to raise awareness of how better to support patients with a hearing impairment (appendix 1). This should enable patients to access support that they require more easily and also raised awareness in staff of the most appropriate methods of providing care for patients with hearing impairments. Both patient facing and staff facing British Sign Language flyers have been developed to raise awareness (appendix 2,3). To address points 2 to 4 and concerns a and b, the Trust held a Round Table review of Mr Bradley’s case on 1st March 2024. The meeting was attended by members of the Urology Team, Cancer Services Team and Patient Safety Team and was multidisciplinary. The purpose of the review was to turn themes identified in to actions and assign them to the appropriate people to make the necessary changes and improvements. The following actions were agreed with named individuals responsible for their delivery: - • Streamline and standardise Urology MDT processes to facilitate appropriate time to discuss cases fully. • Develop a Standard Operating Procedure for the monitoring of potentially cancerous lesions, including transfer of information between teams. • Develop clear process for the handover of patients from Cancer services to Departmental teams if moved off an active cancer tracking process. • Cancer Alert on the Patient Administration System to remain active for the lifetime of the patient • Develop Risk Stratification process within clinical teams for patients who cancel appointments/do not attend. The above actions have varied timelines due to the complexity of some of the issues but will be monitored through the newly developed Improving Safety Action Group, held monthly and chaired by the Chief Nursing Officer/Chief Medical Officer, with first review date scheduled for mid-April 2024. Appendix 1 Appendix 2 Appendix 3 Appendix 1 Our Approach.docx BSL Flyer- patient facing.png BSL Flyer- staff facing.png Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD Office of the Managing Director I trust that the foregoing has adequately addressed the Regulation 28 report issued subsequent to the inquest into the death of Paul Bradley. Should you require any further information in relation to this matter, please do not hesitate to ask. I confirm that I have not forwarded a copy of this response to any other Interested Person and would therefore be grateful if you could do so, as appropriate. I also confirm that the Trust is content for both the regulation 28 report and the response to be released or published should the Chief Coroner wish. Yours sincerely Managing Director Appendices 1. Our Approach 2. BLS Flyer Patient facing 3. BLS Flyer Staff facing Worcestershire Acute Hospitals NHS Trust | Executive Suite, Sky Level 3 | Worcestershire Royal Hospital Charles Hastings Way | Worcester | WR5 1DD
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