Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0519, written 1 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Oct 2024 |
|---|---|
| Reference | 2024-0519 |
| Deceased | Ryan Campbell |
| Coroner | Christopher Murray |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Manchester University NHS Foundation Trust · Stockport NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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: The Secretary of State for Health NHS England Stepping Hill Hospital CORONER Christopher Murray HM Assistant Coroner Manchester South Coronial Area Mount Tabor Stockport CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 1 2 3 INVESTIGATION and INQUEST On 29th August 2023 an inquest was opened into the death of Ryan James Richard Campbell aged 33. At the inquest I concluded that Ryan Campbell died as a result of an acute myocardial infarction due to severe coronary artery atheroma that had not been identified for surgical intervention, which was likely to have resulted in survival, during medical investigation as imaging measures were still awaited at the time of his death. 4 CIRCUMSTANCES OF THE DEATH Ryan Campbell had been suffering with chest pain which prompted him to visit his GP on 15th December 2023. His GP referred him immediately to Stepping Hill Hospital she underwent a series of tests. He was discharged on 16th December 2023 and arrangements were made for follow up tests, namely echo cardiogram, a CT angiogram and a 24 hr heart monitor. The subsequent echocardiogram and 24hr heart monitor did not provide any further diagnostic outcome but his symptoms persisted and he consulted his GP again on 19th January 2024 resulting in a expedite letter sent the same day to the bookings team in the imaging section of the cardiology department. It was not until the 22nd February 2024 that the cardiology team requested an urgent stress 1 echocardiogram which was then scheduled for 3rd April 2024 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 - The absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital, particularly CT or MR angiograms, contributes to delays in diagnosis for patients and the risk of delays is heightened by having to switch treatment centres. This lack of a range of equipment is inconsistent with providing a full cardiology service to patients. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you and/or your organisation 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 26th November 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 following Ryan’s family. HHJ Alexia Durran, the Chief Coroner of England & Wales The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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. 2 9 DATE 1st October 2024 Signed CSMurray HM Assistant Coroner 3
3 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.
From: To: Sent: Wed Dec 04 2024 17:50:37 GMT Subject: External: RE: Ryan James Richard Campbell (deceased) (ref: ) Good afternoon, Thank you for sending the Regulation 28 report to the Department of Health and Social Care in relation to the sad death of Ryan James Richard Campbell. Please accept our sincerest apologies for the delay in responding to this case. The Department has reviewed the concerns outlined in the report. As the procurement of diagnostic equipment at Stockport NHS Foundation Trust falls under the responsibility of the trust and NHS England (NHSE), we have determined that they are better positioned to address the issue and provide an appropriate response. Since NHSE are also a named recipient in the report, we have engaged with them, and they have confirmed receipt of the report and are working on their response. Kind regards, DHSC PFD Oversight Team Quarry House, Quarry Hill, Leeds, LS2 7UE E: Department of Health and Social Care Follow us on Twitter @DHSCgovuk From: Manchester South Coroner < Sent: Tuesday, October 1, 2024 12:56 PM To: DH Coroners Reports < Subject: RE: Ryan James Richard Campbell (deceased) (ref: > > ) Dear Sirs, Our case reference: 35964868 Please find attached a Regulation 28 Report for your attention. Kind regards, Business Support Assistant NOTE: Please do not edit the subject line when replying to this email. A7
Our ref: Your ref: PRIVATE AND CONFIDENTIAL Mr Christopher Murray HM Assistant Coroner Manchester South Coronial Area Mount Tabor Stockport Oak House Stepping Hill Hospital Poplar Grove Stockport Cheshire SK2 7JE Tel: 21 November 2024 Email: Ref: Mr Ryan James Richard CAMPBELL Dear Mr Murray, Further to the inquest you held on 20 September 2024 into the death of the late Mr Ryan Campbell, I am writing to you at your request for further information in relation to the (Associate Medical matter of concern you have raised. I have asked (Consultant Cardiologist) and Director for Medicine and Urgent Care), (Interim Directorate Manager for Cardiology) to review your concerns. Your concern related to: 1) The absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital, particularly CT or MR angiograms, contributes to delays in diagnosis for patients and the risk of delays is heightened by having to switch treatment centres. This lack of a range of equipment is inconsistent with providing a full cardiology service to patients. Stockport NHS Foundation Trust are commissioned for the following diagnostics/services: • Plain Echocardiogram • Stress Echocardiogram • Contrast Echocardiogram • Transoesophageal Echocardiogram (TOE) • Valve surveillance • Electrocardiogram (ECG) • • • • • • Myocardial Perfusion Scan (Radiology) • Tilt Table Test 24hr ECG 72hr ECG 7 day ECG 24hr blood pressure Implantable loop recorder A4 Stockport NHS Foundation Trust are not commissioned for CT or MR angiograms. In Mr Ryan’s case, the CT Coronary Angiogram (CTCA) scan that was requested following his admission to AMU in December 2023 is delivered at Wythenshawe Hospital (Manchester University NHS Foundation Trust). Manchester University NHS Foundation Trust (MFT) have always been the regional provider for this. Some other NHS hospitals in the region do have their own CTCA service (for example, Salford Royal NHS Foundation Trust), but do not accept external referrals. The waiting times for CTCA at Wythenshawe Hospital have unfortunately been increasing for some time. Prior to last year the turnaround time for a CTCA would have been around 6- 12 weeks. However, in the last year this has become around a 6 months turnaround time. Stockport NHS Foundation Trust is not an outlier in terms of being a district general hospital with a cardiology service that does not include a full suite of cardiac diagnostic imaging equipment, particularly CT or MR angiograms. This centralisation of specialist services like this is fairly longstanding and is not unique to Stockport NHS Foundation Trust or the North West Region. The cardiology service would like to expand the services offered on site at Stockport NHS Foundation Trust in the future and CT Coronary Angiogram service provision is on the Division of Medicine and Urgent Care’s service development programme for review next year. Within this review specific areas of focus will be equipment required and cost, radiology and other staffing requirements and availability, and the predicted demand for the service. In Mr Ryan’s case, he had a 6 week wait for an urgent Stress Echocardiogram; which was requested by his GP on 22nd February 2024. An appointment was booked for Mr Ryan for a Stress Echo for 3rd April 2024. This was the earliest appointment available. The waiting list at this time was 5 months. The Trust has made significant progress in relation to Stress Echo waiting times, with an additional 20 lists now planned over weekends which will cover 140 patients and should clear the backlog that the Trust is experiencing. This will bring the waiting time for Stress Echo back to 6 weeks; it is hoped this will be achieved by 31st January 2025. The service will then be achieving the 6-week standard for all patients and urgent referrals will be prioritised and booked from 2 weeks. In terms of plain echocardiogram, the community diagnostic centre (CDC) opened in September 2024 providing the Trust with an additional 74 ECHO slots per week, which has had a direct impact on the waiting times. Patients are now being seen within the expected 6 week timeframe for echos. I would like to express my apologies to Mr Ryan’s family in relation to the delays in diagnostic tests, and offer my sincere condolences for their loss. A5 I trust that the above addresses your concerns. Please do not hesitate to contact the Trust if you require any further information. Yours faithfully Chief Executive A6
Mr Christopher Murray HM Assistant Coroner Manchester South Coronial Area 1 Mount Tabor Street Stockport SK1 3AG National Director of Patient Safety NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 25 November 2024 Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Ryan James Richard Campbell Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1 October 2024 concerning the death of Ryan James Richard Campbell. The circumstances of death section in your Report appears incomplete, and the date of death has not been specified. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Ryan’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Ryan’s care have been listened to and reflected upon. Your Report raised the concern that there was an absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital, particularly CT or MR angiograms, which contributes to delays in diagnosis for patients. My response to your Report has been informed by engagement with NHS Greater Manchester Integrated Care Board, who are the responsible commissioner for the cardiac services delivered within Stockport NHS Foundation Trust where Stepping Hill Hospital sits. Stockport NHS Foundation Trust are commissioned diagnostics/services: for the following • Plain Echocardiogram • Stress Echocardiogram • Contrast Echocardiogram • Transoesophageal Echocardiogram (TOE) • Valve surveillance • Electrocardiogram (ECG) • 24 hour ECG • 72 hour ECG • 7 day ECG A1 Implantable loop recorder • 24 hour blood pressure • • Myocardial Perfusion Scan (Radiology) • Tilt Table Test Stockport NHS Foundation Trust are not commissioned for CT or MR angiograms. In Ryan’s case, the CT Coronary Angiogram (CTCA) scan that was requested following his admission to the Acute Medical unit (AMU) in December 2023 is delivered at Wythenshawe Hospital (part of Manchester University NHS Foundation Trust). Manchester University NHS Foundation Trust (MFT) have always been the regional provider for this. Some other NHS hospitals in the region do have their own CTCA service (for example, Salford Royal Hospital) but do not accept external referrals. The waiting times for CTCA at Wythenshawe Hospital have unfortunately been increasing for some time. Previously, the turnaround time for a CTCA would have been around 6-12 weeks. However, in the last year this has become around a 6 month turnaround time. Stockport NHS Foundation Trust is not an outlier in terms of being a district general hospital with a cardiology service that does not include a full suite of cardiac diagnostic imaging equipment, particularly CT or MR angiograms. The centralisation of specialist services like this is longstanding and is not unique to Stockport NHS Foundation Trust or the North West region. The Trust’s cardiology service would like to expand the diagnostics/services offered on site at Stepping Hill Hospital in the future and CT Coronary Angiogram service provision is on the Division of Medicine and Urgent Care’s service development programme for review next year. Within this review, the specific areas of focus will be equipment required and cost, radiology and other staffing requirements and availability, and the predicted demand for the service. The Trust has no plans to develop an MR angiogram service at this stage. In Ryan’s case, he had a 6 week wait for an urgent Stress Echocardiogram, which was requested by his GP on 22nd February 2024. An appointment was booked for Ryan for 3rd April 2024. This was the earliest appointment available. The waiting list at this time was 5 months. The Trust has made significant progress in relation to Stress Echocardiogram waiting times, with an additional 20 lists now planned over weekends which will cover 140 patients and should clear the backlog that the Trust is experiencing. This will bring the waiting time for Stress Echocardiograms back to 6 weeks; it is hoped this will be achieved by 31st January 2025. The service will then be achieving the 6 week standard for all patients and urgent referrals will be prioritised and booked from 2 weeks. In terms of plain echocardiograms, the community diagnostic centre (CDC) opened in September 2024, providing the Trust with an additional 74 echocardiogram slots per week, which has had a direct impact on the waiting times. Patients are now being seen within the expected 6-week timeframe for a plain echocardiogram. A2 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 events, such as the sad death of Ryan, 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 Director of Patient Safety A3
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