University Hospitals Birmingham NHS Foundation Trust
NHS / Health Body
Action Planned
The Trust will appoint a consultant haematologist with oversight over the stem cell lab and investigations and work up of patients, and are entering discussions with NHSBT to create a joint post. They are also identifying funding at UHB by job planning review across the department. (AI summary)
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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 myeloid diseases (acute myeloid leukaemia (AML), myelodysplastic syndrome and 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.
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 myeloid diseases (acute myeloid leukaemia (AML), myelodysplastic syndrome and 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.