Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0230, written 16 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 May 2025 |
|---|---|
| Reference | 2025-0230 |
| Deceased | Tina Doig |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | University Hospitals Birmingham 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 THIS REPORT IS BEING SENT TO: • University Hospitals Birmingham NHS Foundation Trust • Secretary of State for Health • Birmingham and Solihull Integrated Care Service CORONER I am Louise Hunt, HM Senior Coroner for Birmingham and Solihull 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. INVESTIGATION and INQUEST On 2 September 2024 I commenced an investigation into the death of Tina Louise DOIG. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Her death was a consequence of a serious underlying blood cancer which progressed to acute myeloid leukaemia contributed to by sepsis due to prolonged immunosuppression, a failed first stem cell transplant caused by a failure to undertake appropriate testing on the donor and recipient before transplant and a subsequent Stem cell transplant. 1 2 3 4 CIRCUMSTANCES OF THE DEATH Mrs Doig was diagnosed with myelodysplasia (a rare blood cancer) in September 2023. She had an aggressive haematological condition with high-risk features and was at risk of developing acute myeloid leukaemia. The normal treatment for this condition is a stem cell transplant (SCT) which was to be sourced as soon as possible given the risk of progression of her disease. She was initially treated with chemotherapy and her condition went into remission. Mrs Doig had an unusual HLA type which was highly sensitised with many HLA antibodies. This meant any transfusion or SCT needed to be carefully tested to ensure it was suitable for Mrs Doig. Initial attempts were made to identify an unrelated stem cell donor but unfortunately one could not be found. As a result Mrs Doig's 2 sons were tested for haploidentical donors. As the SCT was coming from a son it would always be only a 50% match. It was determined that one of her sons was a suitable donor. During the testing undertaken on her son no virtual crossmatch comparing the donors HLA antibody profile to Mrs Doig’s HLA type was undertaken despite it being known that Mrs Doig had an unusual HLA type with many HLA antibodies. This was due to a failure to appreciate the significance of this testing for Mrs Doig, a communication failure between the hospital and the transfusion service, no additional sample being sent for Mrs Doig and no MDT being undertaken to discuss the treatment being proposed, thus losing the opportunity to discuss existing donor specific antibodies and the risk of SCT graft failure. Mrs Doig was admitted to hospital for pre transplant conditioning on 27/03/24 and received a SCT from on 04/04/24 to which she had an extreme reaction. By 25/04/24 the SCT had not engrafted and further checks were done which identified that there were specific antibodies present which explained the failure of the SCT. Mrs Doig remained in hospital and was treated for infection until she was well enough to be discharged home on 31/05/24. An umbilical cord donor was identified, and Mrs Doig was admitted to hospital on 13/06/24 for pre transplant conditioning before she received a double umbilical cord transplant on 29/06/24. Post transplant Mrs Doig had low grade fevers and raised inflammatory markers and was treated for bacteraemia. Mrs Doig deteriorated on 31/07/24 and was treated for atypical respiratory infection. She was admitted to ITU on 06/08/24 and it was confirmed that the SCT had grafted on 07/08/24. Whilst on ITU she was treated for chest sepsis and developing multi organ failure and had PV bleeding. She remained very unwell and had two cardiac arrests on 14th and 16th August. She sadly passed away later than day. Tests taken during the last days of her life confirmed that sadly her underlying condition had progressed to acute myeloid leukaemia which was untreatable. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1a Multiple organ failure 1b Sepsis due to immunosuppression from stem cell transplants 1c myelodysplasia progressing to acute myeloid leukaemia 1d II failed first stem cell transplant and subsequent second stem cell transplant 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 haematology department at the time of Mrs Doig’s stem cell transplant was understaffed and working beyond its capacity quite often leaving the team with very little time for comprehensive reviews. haematologist at University Hospitals Birmingham NHS Foundation Trust confirmed at the inquest that the position remained the same today. This raises a concern that further deaths will occur and action is required. , consultant 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 July 2025. I, the coroner, may extend the period. 5 6 7 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Tina Doig NHSBT 8 I have also sent it to the Medical Examiner, NHS England, CQC, 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. 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 by the Chief Coroner. 16 May 2025 9 Signature: Louise Hunt Senior Coroner for Birmingham and Solihull
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.
NHS Birmingham and Solihull
Integrated Care Board
8th Floor
Alpha Tower
Suffolk Street
Queensway
Birmingham
B1 1TT
www.birminghamsolihull.icb.nhs.uk
11 July 2025
Mrs Hunt
Senior Coroner for Birmingham and Solihull
By way of email only: coroner@birmingham.gov.uk
Dear Mrs Hunt,
Inquest concerning the death of Tina Doig.
Response to Regulation 28 of the Coroners (Investigations) Regulations 2013.
I am writing in response to the Regulation 28 notice issued following the conclusion of the Inquest held on
15 and 16 May 2025 concerning the death of Mrs Doig, who sadly died on 16 August 2024 at Queen Elizabeth
Hospital Birmingham, part of University Hospitals Birmingham NHS Foundation Trust (UHB).
First and foremost we extend our sincere condolences to Mrs Doig’s family and friends.
We acknowledge the serious concerns raised regarding staffing levels and capacity in the haematology de-
partment at the time of Mrs Doig’s stem cell treatment and the importance of taking meaningful action to
prevent future deaths.
NHS Birmingham and Solihull (BSOL ICB) has carefully considered the issues outlined in your report and is
working closely with UHB to support the actions and recruitment plans detailed in their response to the Reg-
ulation 28 notice dated 8th July 2025.
The ICB takes the recommendations within the Regulation 28 report extremely seriously. We are committed
to support UHB in delivering the necessary improvements to the service and we recognise the importance of
learning from this tragic event to help prevent similar incidents in the future.
If we can be of any further assistance at this time, please do not hesitate to contact me.
Yours sincerely
Chief Executive, ICB NHS Birmingham and Solihull
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 24 July 2025 Our ref: HM Coroner Louise Hunt The Birmingham and Solihull Coroner’s Court, Steelhouse Lane, Birmingham B4 6BJ By email: Dear Ms Hunt, Thank you for the Regulation 28 report of 16 May 2025 sent to the Secretary of State about the death of Mrs Tina Louise Doig. I am replying as the Minister with responsibility for Secondary Care. Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Doig’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns that the Trust’s haematology department at the time of Mrs Doig’s stem cell transplant was understaffed, often leaving very little time for comprehensive reviews to be carried out. A consultant haematologist from the Trust confirmed this situation was continuing at the time of the inquest. Individual NHS Trusts and other employers are responsible for ensuring that there are sufficient staff to provide safe care. I would expect NHS Trusts and other relevant organisations to review their staffing levels, including in non-patient facing roles, to ensure that they are appropriate in the wake of the death of Mrs Doig. Trusts already have a duty through Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to regularly review the number of staff and range of skills needed to safely meet the needs of people using their services. I note that you have also sent this report to University Hospitals Birmingham NHS Foundation Trust, and Birmingham and Solihull Integrated Care Service and expect that they will respond regarding the concerns about the services involved. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
8th July 2025 STRICTLY PRIVATE AND CONFIDENTIAL ADDRESSEE ONLY For the attention of Mrs Louise Hunt Senior Coroner for Birmingham and Solihull Sent by way of email only: Dear Mrs Hunt Inquest touching the death of Tina Doig Response to Regulation 28 Report to prevent future deaths I am writing in response to the Regulation 28 notice issued following the conclusion of the Inquest on 15 and 16 May 2025 touching the death of Mrs Doig who died on 16 August 2024 at Queen Elizabeth Hospital Birmingham (part of University Hospitals Birmingham NHS Foundation Trust (UHB)). The matter of concern was: The inquest heard evidence that the haematology department at the time of Mrs Doig’s stem cell transplant was understaffed and working beyond its capacity quite often leaving the team with very little time for comprehensive reviews. , consultant haematologist at University Hospitals NHS Foundation Trust confirmed at the inquest that the position remained the same today. This raises a concern that further deaths will occur, and action is required. University Hospitals Birmingham NHS Foundation Trust and the Department of Haematology at Queen Elizabeth Hospital Birmingham were deeply saddened by the death of Mrs Doig and recognise that there were deficiencies in her care for which we offer our unreserved apologies. As you heard at the Inquest, process failings in the pathway through which Mrs Doig’s pre- transplant care was managed led to the failure to recognise that she had significant levels of donor-specific antibodies against her son who was her prospective haplo-identical donor. Had information about the donor specific antibodies been available to the haematology team pre- transplant, it would have been incorporated into decision making relating to her care and shared with Mrs Doig and her family. Due to a failure of communication between NHSBT & UHB, this did not happen. Following the discovery of this communication failure, the pathway underpinning SCT work- up and care was rapidly reviewed, and immediate measures were put in place to mitigate continuing risks. These mitigations were scrutinised and further expanded through the learning response (LR) investigation that UHB undertook in collaboration with NHSBT. As described in evidence presented to the Inquest, both organisations are satisfied that the co-produced changes to the pathway for SCT will secure the care of current and future patients at UHB. In monitoring the safety of the Stem Cell Transplant Programme, UHB also takes assurance from its external accreditation provided by the Joint Accreditation Committee of the International Society for Cellular Therapy & the European-group for Bone Marrow Transplant (JACIE). Certification is the means by which a centre demonstrates that it is performing a required level of practice in accordance with agreed standards of excellence and operates an effective quality management system. UHB’s Stem Cell Transplant Programme was inspected over 2 days in March 2024 and was recertified on the basis of that inspection with only minor actions to be implemented. The European Blood and Marrow Transplantation (EBMT) Benchmarking Group issued its most recent Report of Outcomes After Haematopoietic SCT to UHB in February 2025. The data covered in this report related the period 2018-2022. One-hundred-day survival, one year survival and one year relapse/mortality for the UHB cohort benchmarked as ‘in-range’ when compared to an international registry of over 61,000 procedures. Local monitoring of the clinical quality and safety of the Stem Cell Transplant Programme is undertaken by the department through regular M&M meetings and overseen by Hospital Quality and Safety Committee which reports to Group Care Quality Meeting. We have provided this summary of the monitoring and accreditation of the Stem Cell Transplant Programme at UHB and highlighted pathway changes which have been implemented following our investigation into Mrs Doig’s death because we consider that these are relevant to the safety and quality of care which our patients should expect now and in the future and to the Regulation 28 Report. At the same time, we recognise that like many clinical services across the NHS, the Stem Cell Transplant Programme at UHB currently faces significant operational pressures. We acknowledge that robust consultant staffing levels are an essential component of the delivery of safe, high-quality care and we are working with our Haematology team to ensure that the SCT Programme is sufficiently resourced. During the pandemic, the Departments of Haematology across both Queen Elizabeth Hospital and Birmingham Heartlands Hospitals (now combined) underwent substantial reorganisation which saw significant changes in their consultant faculty. Over the last 5 years, successful recruitment to the Department of Haematology has led to a significant increase in the number of substantive Haematology consultants working at the Trust but notably, multiple sub- specialty areas within the Department have required investment and additional consultants which has created a challenging landscape. Despite these pressures, SCT activity has continued to grow with the team performing 109 allogenic SCT procedures in 2024, compared with an average of 76 procedures per year between 2018 and 2022 . This is in addition to ~145 autologous SCT procedures per annum. We fully accept that the dedication, skill and efficiency of the UHB SCT team in delivering this highly specialised treatment necessitates additional investment with an augmentation of senior medical staffing in the SCT team as soon as is practicable. At the time of the treatment and death of Mrs Doig, the consultant transplant team treating leukaemia (AML), myelodysplastic syndrome and myeloid diseases (acute myeloid myeloproliferative neoplasia) consisted of three transplant consultants. In order to provide an immediate increase in capacity, one of our existing transplant consultants has been re-job planned from 1st July 2025 to reduce their general haematology clinic commitments and increase transplant-dedicated time, increasing their capacity to manage new and post-transplant AML patients. In addition, our senior specialist registrar, who has been working in the myeloid/ transplant clinic and is due to receive their certificate of completion of training (CCT) in August, and will enter a 6-month extended training period during which they will focus on increasing their sub speciality experience in myeloid disease and allogeneic stem transplantation. They are already beginning to work semi-independently with consultant supervision and are directly supporting transplant clinics. The extension to training has been agreed with NHSE WTEd (West Midlands Deanery). Our medium-term strategy is to create two additional consultant posts in transplant medicine, for which funding has been identified. The first appointment will be a myeloid transplant consultant, and the aforementioned trainee would be well suited to apply for this post when it is advertised. The second post is a joint appointment with NHS Blood and Transplant (NHSBT). The post will have a commitment to work 50% for NHSBT Cell, Apheresis, and gene therapies (CAGT) team and will be part of the transplant and cellular therapy team at NHSBT. The other 50% of time will be spent working within the transplant and cellular therapy team at UHB, part of which will involve treatment of AML patients requiring stem cell transplants. Working across UHB and NHSBT will give the consultant oversight over the stem cell lab and investigations and work up of patients, providing an increase in the safety and monitoring of patients going through transplant. The appointee will ensure that coherent communication between NHSBT and UHB consultants is sustained, facilitating effective discussion and information sharing on treatment, stem cell products and investigations required in this complex area. Similar posts already exist in other transplant units (Oxford, Leeds, Manchester amongst others) and we are confident that the joint UHB-NHSBT CAGT post will be successfully recruited. We are entering discussions with NHSBT to create the post and are in the process of identifying funding at UHB by job planning review across the department. Notably, our ability to work collaboratively across the 2 NHS organisations has been established through our joint NHSBT-UHB appointed Transfusion Medicine consultant who has been in post for over 5 years. The Hospital Medical Director at Queen Elizabeth Hospital will monitor the recruitment to these new posts and report progress to the Hospital Executive Director through the Hospital Board. In the longer term, we will look to explore options for further investment through discussions with our commissioners based on the level of transplant activity and our continuing over-performance. We hope that the actions and planned recruitment described herein will offer you sufficient assurance that the Trust has taken sufficient steps to comply with the Regulation 28 Report to Prevent Future Deaths. Finally, we wish to reiterate that we are deeply sorry that Mrs Doig’s care became a significant concern to you and to her family and that we are committed to making necessary improvements to the service. Yours sincerely , Chief Executive Officer
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