Warrington Hospitals
NHS / Health Body
Action Planned
Warrington and Halton Hospitals will discuss the case and associated issues at the Radiology Governance Meeting on 19 August 2024. Radiologists will also present the case and concerns to the Cheshire and Merseyside Radiology Imaging Network (CAMRIN) on 17 September 2024. (AI summary)
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Dear Ms Keighley Re: Inquest into the death of Mr David Scott We write regarding the inquest into the death of Mr Scott which concluded on 22 2024 in which you issued a Regulation 28 Report to Prevent Future Deaths ("Regulation 28 Report")_ we take this opportunity to express our sincere condolences to the family of Mr Scott: We understand that the Regulation 28 Report was issued on the basis that vascular calcification was not reported on a knee X-Ray performed in the Emergency Department in February 2023. We understand that your concern is that such a finding; which could be normal or abnormal, was not included in the X-Ray report and you are concerned that the non-inclusion of such a finding in future reports poses a risk that future deaths may occur: We, along with the medical teams in the Emergency Department and Radiology Department; have carefully considered your conclusion and outline below our response and the actions which the Trust will undertake to reduce the risk of further such harm For clarity these are presented below in 3 subsections: Clinical assessment of ulcers and recognition of peripheral vascular disease in the Emergency Department_ 2 Completeness of clinical details on imaging requests_ 3_ Reporting standards in the context of incidental findings. Chair: Chief Executive: 999199061 Floor May May leg
[HS Warrington and Halton Teaching Hospitals NHS Foundation Trust Corporate Nursing & Governance Department First Floor Kendrick Warrington and Halton Hospitals Foundation Trust Lovely Lane; Warrington, Cheshire WAS 1QG Email Clinical assessment of leg ulcers and recognition of peripheral vascular disease in the Emergency Department Peripheral Vascular Disease (PVD) is typically a clinical diagnosis, which is then initially investigated with Doppler USS before usually being confirmed and further characterised with CT Angiography. This diagnostic process requires an initial index of suspicion for PVD during the assessment of wounds; with a painful non-healing ulcer prompting further history taking and clinical examination to elicit other clinical features of PVD: This did not occur in Mr David Scott's case_ To reduce the risk of a future similar omission we will ensure that all of our Emergency Department Medical Team receive further training and education in the clinical assessment of leg wounds and vascular assessment of patients with chronic limb wounds_ 2 Completeness of clinical details on imaging requests Had the clinical assessment correctly raised the suspicion of PVD (as outlined above) this would have prompted additional imaging in addition to a plain X ray to effectively investigate for possible PVD. Similarly had the imaging request included information regarding the nature of the wound (specifically it being non-healing and painful) , this would have raised the clinical suspicion of the wound being an ischaemic injury and likely elevated the vascular calcification seen on X ray from a common and asymptomatic incidental finding to a more important part of the clinical picture_ In the absence of the above relevant clinical information, in line with national reporting standards, the reporting radiologist had no reason to suspect that the vascular calcification was of any clinical significance and as such this was not reported nor were alternative, more appropriate investigations for PVD advised by the reporting radiologist: Effective reporting is dependant on accurate and complete clinicaFinformation on imaging requests, which were lacking in this case. Our Radiology Department will work with the Emergency Department to undertake specific education and teaching with regards to the standards and quality of clinical information required to ensure effective reporting: To ensure that change is sustained and to identify further areas for learning and improvement; the Emergency Department and Radiology Department will undertake a joint clinical audit of the quality of clinical information on imaging investigation requests at a frequency to be determined based on the findings of the first baseline audit: Chair: Chief Executive:
999199061.- Wing, leg
NHS Warrington and Halton Teaching Hospitals NHS Foundation Trust Corporate Nursing & Governance Department First Floor Kendrick Warrington and Halton Hospitals Foundation Trust Lovely Lane, Warrington, Cheshire WAS 1QG Email 3 Reporting standards in the context of incidental findings As stated in the written evidence submitted to the inquest; vascular calcification is common in older patients and is often seen incidentally on imaging studies in patients without clinical features of PVD ; Studies suggest the prevalence of vascular calcification increases with age, and it is not routinely reported unless clinical information on the imaging request is suggestive %f a clinical diagnosis of PVD, the calcification is severe or is associated with an aneurysm: The presence and extent of vascular calcification on does not correlate with PVD symptoms or severity and for this reason, X-rays are not used in the diagnosis of peripheral vascular disease Mr Scotts knee X-Ray showed mild vascular calcification without evidence of an aneurysm and therefore; in the absence of clinical information suggestive of PVD on the imaging request, this finding was not mentioned in the report; Our Radiologists confirm this is in line With national practice and guidance (the Standards for Interpreting and Reporting of Imaging Investigations produced by the Royal College of Radiologists) The Radiology Team have tabled an agenda item at the Radiology Governance Meeting for wider discussion of this case and associated issues as outlined above This meeting is due to take place on 19 August 2024. Our Radiologists will also present this case and your concerns to the Cheshire and Merseyside Radiology Imaging Network (CAMRIN), collaboration of 12 Trusts from across the Cheshire and Merseyside Integrated Care System (ICS) that have come together to work on a large-scale change programme that aims to improve radiology services for patients and staff. This meeting is due to take place on 17 September 2024_ The Trust is always keen to review, learn and wherever possible, strengthen our clinical processes and so we are grateful for your bringing these concerns to our attention: We hope the above offers you reassurance of the Trust's ongoing commitment to managing patient safety risks and continually improve the services we provide_
[HS Warrington and Halton Teaching Hospitals NHS Foundation Trust Corporate Nursing & Governance Department First Floor Kendrick Warrington and Halton Hospitals Foundation Trust Lovely Lane; Warrington, Cheshire WAS 1QG Email Clinical assessment of leg ulcers and recognition of peripheral vascular disease in the Emergency Department Peripheral Vascular Disease (PVD) is typically a clinical diagnosis, which is then initially investigated with Doppler USS before usually being confirmed and further characterised with CT Angiography. This diagnostic process requires an initial index of suspicion for PVD during the assessment of wounds; with a painful non-healing ulcer prompting further history taking and clinical examination to elicit other clinical features of PVD: This did not occur in Mr David Scott's case_ To reduce the risk of a future similar omission we will ensure that all of our Emergency Department Medical Team receive further training and education in the clinical assessment of leg wounds and vascular assessment of patients with chronic limb wounds_ 2 Completeness of clinical details on imaging requests Had the clinical assessment correctly raised the suspicion of PVD (as outlined above) this would have prompted additional imaging in addition to a plain X ray to effectively investigate for possible PVD. Similarly had the imaging request included information regarding the nature of the wound (specifically it being non-healing and painful) , this would have raised the clinical suspicion of the wound being an ischaemic injury and likely elevated the vascular calcification seen on X ray from a common and asymptomatic incidental finding to a more important part of the clinical picture_ In the absence of the above relevant clinical information, in line with national reporting standards, the reporting radiologist had no reason to suspect that the vascular calcification was of any clinical significance and as such this was not reported nor were alternative, more appropriate investigations for PVD advised by the reporting radiologist: Effective reporting is dependant on accurate and complete clinicaFinformation on imaging requests, which were lacking in this case. Our Radiology Department will work with the Emergency Department to undertake specific education and teaching with regards to the standards and quality of clinical information required to ensure effective reporting: To ensure that change is sustained and to identify further areas for learning and improvement; the Emergency Department and Radiology Department will undertake a joint clinical audit of the quality of clinical information on imaging investigation requests at a frequency to be determined based on the findings of the first baseline audit: Chair: Chief Executive:
999199061.- Wing, leg
NHS Warrington and Halton Teaching Hospitals NHS Foundation Trust Corporate Nursing & Governance Department First Floor Kendrick Warrington and Halton Hospitals Foundation Trust Lovely Lane, Warrington, Cheshire WAS 1QG Email 3 Reporting standards in the context of incidental findings As stated in the written evidence submitted to the inquest; vascular calcification is common in older patients and is often seen incidentally on imaging studies in patients without clinical features of PVD ; Studies suggest the prevalence of vascular calcification increases with age, and it is not routinely reported unless clinical information on the imaging request is suggestive %f a clinical diagnosis of PVD, the calcification is severe or is associated with an aneurysm: The presence and extent of vascular calcification on does not correlate with PVD symptoms or severity and for this reason, X-rays are not used in the diagnosis of peripheral vascular disease Mr Scotts knee X-Ray showed mild vascular calcification without evidence of an aneurysm and therefore; in the absence of clinical information suggestive of PVD on the imaging request, this finding was not mentioned in the report; Our Radiologists confirm this is in line With national practice and guidance (the Standards for Interpreting and Reporting of Imaging Investigations produced by the Royal College of Radiologists) The Radiology Team have tabled an agenda item at the Radiology Governance Meeting for wider discussion of this case and associated issues as outlined above This meeting is due to take place on 19 August 2024. Our Radiologists will also present this case and your concerns to the Cheshire and Merseyside Radiology Imaging Network (CAMRIN), collaboration of 12 Trusts from across the Cheshire and Merseyside Integrated Care System (ICS) that have come together to work on a large-scale change programme that aims to improve radiology services for patients and staff. This meeting is due to take place on 17 September 2024_ The Trust is always keen to review, learn and wherever possible, strengthen our clinical processes and so we are grateful for your bringing these concerns to our attention: We hope the above offers you reassurance of the Trust's ongoing commitment to managing patient safety risks and continually improve the services we provide_