Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0693, written 22 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 | 22 Oct 2024 |
|---|---|
| Reference | 2024-0693 |
| Deceased | Richard Roe |
| Coroner | Simon Milburn |
| Coroner area | Cambridgeshire & Peterborough |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1. NORTH WEST ANGLIA NHS FOUNDATION TRUST 1 CORONER I am SIMON MILBURN, Area Coroner, for the coroner area of Cambridgeshire & Peterborough 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 25 January 2023 I commenced an investigation into the death of Richard David ROE aged 75. The investigation concluded at the end of the inquest on 17 October 2024. The conclusion of the inquest was that: Mr Roe underwent a pulmonary angiogram at Hinchingbrook Hospital in Huntingdon on 26.09.21. This revealed a pancreatic cyst. A subsequent CT scan on 11.10.21 identified a lesion in excess of 3cm in the tail of the pancreas. The reporting radiologist recommended the scan be reviewed by the Hepato-Biliary MDT but the scan was neither actioned nor viewed. Had it been viewed the scan would have shown the presence of pancreatic cancer. Mr Roe re-presented to Hinchingbrook Hospital in November 2022 and a subsequent CT scan revealed the presence of metastatic pancreatic cancer. Sadly Mr Roe died at his home address, Had his pancreatic cancer been identified in October 2021 it is likely that Mr Roe would have undergone surgery and been treated with subsequent chemotherapy. Although the chance of the treatment being curative was low had treatment been provided he would not have died as soon as 20.01.23. , at 0832hrs on 20.01.23. 4 CIRCUMSTANCES OF THE DEATH Mr Roe underwent an abdominal CT scan in October 2021. This showed evidence of pancreatic cancer. The CT scan was the subject of a routine referral by the reporting radiologist due to the fact that an earlier pulmonary angiogram had identified a pancreatic cyst(so it was not flagged as an ‘unexpected finding’). The CT scan was not reviewed or actioned as requested by the radiologist. A subsequent CT scan conducted on 01.12.22 revealed that the pancreatic cancer had metastasised. Mr Roe died on 23.01.23. 5 CORONER’S CONCERNS During the course of the investigation my inquiries 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 MATTERS OF CONCERN are as follows: Regulation 28 – After Inquest Document Template Updated 30/07/2021 (1) The evidence revealed that there is currently no method for ensuring that routine CT scan reports are reviewed by clinicians. This is despite a similar occurrence in May 2021. The inquest heard that the Trust are investigating a new IT System which will be able to flag when such issues occur. However this is a medium/long term project with no current completion date known and there is no system in place at present to prevent a repeat of such an incident. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe 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 December 17, 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; Mr Roe’s Family/Legal Representatives I have also sent it to the Integrated Care Board who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Dated: 22/10/2024 Simon MILBURN Area Coroner for Cambridgeshire and Peterborough Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
North West Anglia Our Ref: Po NHS Foundation Trust 13" December 2024 Legal Services Department Stamford & Rutland Hospital Mr Simon Milburn Ryhall Road HM Area Coroner for Cambridgeshire & Peterborough Stamford Lincolnshire Lawrence Court Princes Street HUNTINGDON PE29 3PA PEO 1UA Tel 01733 678323 Dear Sir Richard ROE dec’d Further to the recent inquest into the death of Richard Roe this is to address the issue raised in the Regulation 28 Report dated 22™ October 2024 concerning the method by which we can ensure that routine Cl’ scan reports are reviewed by clinicians. Reviewing scan reports appropriately and timeously has always been, and will remain, the primary responsibility of the clinicians who requested them and /or their departments. However that failed for Mr Roe and we accept that there needs to be a system to ensure that routine scans aren’t overlooked which isn’t dependent on individual clinicians or their departments. ‘The ‘Trust is in the process of improving its clectronic records system so that it is comprehensive and inches all reports requested by clinicians including radiology reports. ‘This is a substantial financial investment by the Trust both in terms of the technology and the staff time needed to implement it. ‘The details of the system haven’t yet been finalised but it will give the ‘Trust more management and audit options and it is expected to include an easier ability to track the viewing of all types of reports including those for routine radiology scans. However, as you noted, the implementation of the improved records system is some way off and as stem and it can, and will, an interim measure we've reviewed the abilities of the current radiology 8) produce reports of unviewed scans (initially monthly) which can then be followed up with the requesting clinicians and/or their departments. The ability of the present system to provide information in detail is limited and at the moment it will identify a large number of unviewed images (most of which would be expected and not a concern) but in liaison with the external providers of the system we expect to be able to refine the information to better identify any scans that have been overlooked. I hope this demonstrates the steps we're taking to try to avoid routine scans being overlooked for long periods before the implementation of the improved electronic records system, Yours faithfully Legal Adviser
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