Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0708, written 23 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Dec 2024 |
|---|---|
| Reference | 2024-0708 |
| Deceased | William Hare |
| Coroner | Rebecca Mundy |
| Coroner area | Essex |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Mid and South Essex NHS Foundation 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: Chief Executive Officer of Mid and South Essex NHS Foundation Trust, 1 CORONER I am Rebecca Mundy, HM Assistant Coroner, for the coroner area of Essex. 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 8 February 2024 I commenced an investigation into the death of William Charles Hare (Bill), 71. The investigation concluded at the end of the inquest on 3 December 2024. The conclusion of the inquest was a narrative conclusion outlining that Mr Hare had died from metastatic urothelial cancer, contributed to by neglect, namely delays to diagnosis and treatment resulting in the cancer spreading to such an extent any treatment that could have been given, became futile. 4 CIRCUMSTANCES OF THE DEATH Bill presented to Basildon Hospital in November 2022 with abdominal and left loin pain. Following CT scans and discussion at a Multi‐Disciplinary Team (MDT) meeting, it was suspected that Bill had cancer in the middle‐left ureter. The MDT determined that an MRI and CT chest be carried out as well as a consultation with Bill. The MRI showed no obvious urothelial lesions and so the advice was that if concerns remained, a ureteroscopy was recommended. Following a consultation with Bill on 4 January 2023 a ureteroscopy was requested. This was undertaken on 16 February. The results of the biopsy were available on 7 March but were inconclusive. The MDT considered next steps on 21 March and advised that imaging and biopsy be repeated with a view to a nephroureterectomy being undertaken. A telephone consultation took place with Bill on 27 March and he was referred to a Consultant Urological Surgeon. Bill was not seen until 23 May. The Consultant adopted the plan set by the MDT, although he felt that Bill would ultimately require surgical intervention. A CT scan was repeated on 5 June but it wasn’t until 29 August that Bill’s case and ongoing plan was next reviewed by the MDT. No one giving evidence could explain that delay. It was decided that given the delays Bill should proceed to have surgery; either a segmental ureterectomy or a nephroureterectomy. 1 Bill attended a pre‐assessment clinic on 4 September, but due to an elevated HBA1c of 104 he was deemed unfit for surgery and instructions were given that he was to be seen in the Diabetic Clinic and re‐referred when his HBA1c was below 70. In the meantime, Bill presented to Basildon hospital again on 3 October with hyponatremia secondary to diarrhoea and hyperglycaemia secondary to poorly controlled diabetes. His left kidney showed very poor function. There was no evidence of bone metastasis. He was discharged on 25 October. However, he presented again on 17 November with low sodium and sepsis with a left nephrostomy tube. Further scans and investigations were undertaken but no positive action was taken in progressing Bill’s diagnosis or treatment plan. By the time an MRI was undertaken on 20 December, there was evidence of disease progression. Bill was due to be moved to Southend Hospital for specialist treatment by the renal team during this admission, however, due to a combination of a lack of beds, ward closures, junior doctor strikes, a full ITU and issues with transport, he remained in Basildon until 3 January 2024. By this time, his cancer had metastasised to his bladder and psoas muscle. A further CT scan, the results of which only became available on 15 January, revealed that it has also spread to his lungs. Treatment had become futile. Bill was placed on an end‐of‐life care plan and moved to a hospice where he passed away on 23 January. 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 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. – i. There was an overall delay in reaching any diagnosis in Bill’s case and, therefore, any treatment plan being implemented. ii. There was a delay in the first biopsy being taken which ultimately took place well outside the national guideline of 31 days. iii. There was a delay from the MDT referring the case to the Consultant, to an appointment taking place in May 2023. iv. There was an additional delay between the further CT scan ordered by the Consultant, which took place on 5 June, and the MDT which considered the results and treatment plan on 29 August, notwithstanding the fact that the MDT meet weekly and Bill’s case 2 could have been considered at any of those meetings. v. A further delay occurred from 4 September, as Bill had been assessed as unfit for surgery due to his HBA1c reading. Whilst this is unlikely to have been related to the cancer, there was likely to have been an opportunity, had his case been progressed earlier, at which his HBA1c was at an acceptable level for the procedure to be carried out. vi. In his last admission to Basildon Hospital between November 2023 and January 2024 there were delays in progressing his treatment due to the disjointed nature of the inter‐relationship between Basildon and Southend Hospitals as well as delays in transporting him to Southend Hospital which included failures to organise transport and properly coordinate his transfer. vii. A final delay occurred in the results of a CT scan, the results of which were not available until 15 January. By this time, the cancer had spread throughout Bill’s body and became untreatable. viii. Among the delays, and potentially contributing to them, were a series of systemic and procedural errors largely related to processes controlled by isolated computer systems or people who are not medically trained. One example is the default of a referral or request to “routine”. ix. The lack of a specialist renal consultant at the MDT and lack of effective interaction between the people and systems at Southend and Basildon Hospitals prevented quick and effective decision making and, therefore, progress of Bill’s diagnosis and treatment. 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 17 February 2025. 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 Bill’s family. I have also sent it to The Care Quality Commission, who may find it useful or of interest. 3 Further, I am 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 23 December 2024 Rebecca MUNDY, HM Assistant Coroner 4
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.
H.M Assistant Coroner Ms Rebecca Mundy SEAX House Victoria Road South Chelmsford Essex CM1 1QH Our Ref: 17 February 2025 Dear Ms Mundy Regulation 28 Report to Prevent Future Deaths- William Hare I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated 20th December 2024, relating to the Inquest of Mr William Charles Hare (Bill). We have considered your concerns and set out our formal response to each matter using your numbering as follows. Matters of Concern Diagnostic stage I. There was an overall delay in reaching any diagnosis in Bill’s case and, therefore, any treatment plan being implemented. II. III. There was a delay in the first biopsy being taken which ultimately took place well outside the national guideline of 31 days. There was a delay from the MDT referring the case to the Consultant, to an appointment taking place in May 2023. We have reflected on Mr Hare’s experience and carefully considered how the patient pathway and treatment timescales could be improved. We have made significant improvements to our diagnostic pathways including increased clinic capacity and designated consultant presence at all of our clinics. This is greatly reducing the diagnosis timescales for patients and improving overall patient experience. 1 We have improved the quality of care delivered at our pre-assessment clinics. Specialist staff are now reviewing clinic lists for patients such as Mr Hare, where HBA1c is poorly controlled and would benefit from early support from the hospital. We know that hospital led support yields the best outcomes for these patients, and so we have increased clinical capacity in this area. In doing so we monitor any deterioration of HBA1c control and work closely with our patients to counsel them on the impact this may have on the future treatments we can offer. A further key development is the creation of a focused weekly kidney/upper tract urological cancers MDT (multi-disciplinary team) meeting. By separating this MDT from the general pelvic MDT, patients with suspected upper tract urological cancers are reviewed in a very timely manner and it is our routine practice to review all relevant patient scans taken within the past 7 days. We are not experiencing any delays between scans and the MDT review and patient clinics to review results are happening, and within the timescale prescribed within the cancer pathway. IV. There was an additional delay between the further CT scan ordered by the Consultant, which took place on 5 June, and the MDT which considered the results and treatment plan on 29 August, notwithstanding the fact that the MDT meet weekly, and Bill’s case could have been considered at any of those meetings. We now have one comprehensive patient tracking system for all hospital sites providing a centralised monitoring for all cancer patients and their progress through the cancer pathway. The new system mitigates the risk of procedural errors and allows full visibility of patients’ progress and treatment pathways across all hospital sites. Delays are minimised as the service can track diagnostic reporting. Clinicians view their patient’s status, including progress of any diagnostic procedures requested using the tracker, and any deviance from expected timescales or delays prompts action and encourages escalations to occur where required. We are confident that scans are being reviewed by the MDT without delay. As explained above, we now have a specialist kidney/upper tract urological cancer MDT meeting held each week and the expectation of the group is that all relevant patients who had scans completed in the week before the meeting are discussed. V. A further delay occurred from 4 September, as Bill had been assessed as unfit for surgery due to his HBA1c reading. Whilst this is unlikely to have been related to the cancer, there was likely to have been an opportunity, had his case been progressed earlier, at which his HBA1c was at an acceptable level for the procedure to be carried out. 2 My colleagues advise me that Mr Hare’s HBA1c control was unfortunately in decline since his first presentation at the preassessment clinic on 4th September 2023. We cannot speculate that Mr Hare would have been a suitable candidate for the procedure at an earlier date as his HBA1c was never optimal for surgery and he was at high risk of complications including stroke. Poorly controlled HBA1c places patients at risk of death from such procedures and these risks were explained to Mr Hare when the clinical decision was that he was at too high a risk for surgery at that time. He was referred to his GP for HBA1c optimisation. We have improved our pre-operative assessments and management of HBA1c to include consultant led support so that patients such as Mr Hare are identified as early as possible and offered in house endocrinology support to control their HBA1c. Communication & transfer VI. In his last admission to Basildon Hospital between November 2023 and January 2024 there were delays in progressing his treatment due to the disjointed nature of the inter‐relationship between Basildon and Southend Hospitals as well as delays in transporting him to Southend Hospital which included failures to organise transport and properly coordinate his transfer. We acknowledge that there were issues with inter hospital transfers and delays, however in this case transferring from Basildon to Southend had no bearing on the clinical outcome as Mr Hare was receiving appropriate care in Basildon HDU. However, we appreciate there should have been better communication at this time with the patient and his family. Should a patient require urgent transfer for specific treatment this is prioiritised by the Trust and the East of England ambulance service. Radiology results VII. A final delay occurred in the results of a CT scan, the results of which were not available until 15 January. By this time, the cancer had spread throughout Bill’s body and became untreatable. Our review of Mr Hare’s records confirms the MRI and X-ray were completed as requested on 5th January 2024, however the CT scan was not carried out until 15th January. Unfortunately, we believe this delay was contributed to by the junior doctor’s strike that took place between 3rd January 2024 - 9th January 2024. The CT scan took place on the 15th January 2024 as this was the first available date once the service resumed normal practice. On review of Mr Hare’s MRI scan taken on 5th January 2024 and his clinical presentation at that time, regrettably the disease progression had made his condition inoperable, and surgery would not have been the appropriate treatment. 3 VIII. Among the delays, and potentially contributing to them, were a series of systemic and procedural errors largely related to processes controlled by isolated computer systems or people who are not medically trained. One example is the default of a referral or request to “routine”. Following the Inquest, we have investigated the concerns raised about the computer systems. I would like to assure you that we have not observed any issues as described at Inquest where requests are downgraded to routine when raised as urgent. As explained in response to point IV above, we now have one comprehensive patient tracking system covering all hospital sites which provides centralised tracking for all cancer patients. The new system mitigates the risk of procedural errors and clinicians can monitor the progress of diagnostic reporting, prompt appropriate action and encourage escalation where necessary. IX. The lack of a specialist renal consultant at the MDT and lack of effective interaction between the people and systems at Southend and Basildon Hospitals prevented quick and effective decision making and, therefore, progress of Bill’s diagnosis and treatment. We are confident that these concerns have been addressed by the development of our kidney/upper tract urological cancer specific MDT meetings which take place following the general MDT each week. The MDT’s take place in a hybrid fashion (online and in person) and involve all three hospital sites. They are well attended by the teams including the specialist renal consultant, consultant surgeons, the lead anesthetist as well as our consultant physicians. The implementation of the new centralised system allows more effective team working across hospital sites and services. Together with the improvements made to our pre assessment clinics we are identifying patients who require additional support with HBA1c at a much earlier stage and improving treatment options and outcomes. We are currently undertaking a review of service demand and capacity for the MSE urology service with the objective to ‘right size’ the capacity in terms of workforce, equipment, and theatre lists. We are positive that this will support our ongoing improvements to patient pathways and experience in the future. 4 If I can assist further with these matters, please do not hesitate to contact me. Yours sincerely Chief Executive Mid and South Essex NHS Foundation Trust 5
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