Source · Prevention of Future Deaths

Michael Daft

Ref: 2023-0475 Date: 24 Nov 2023 Coroner: Sarah Wood Area: Nottinghamshire 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner noted a lack of effective communication between multi-disciplinary teams from different specialisms when a patient is on more than one treatment pathway.

Date 24 Nov 2023

56-day deadline 19 Jan 2024 est. estimated from the report date

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner noted a lack of effective communication between multi-disciplinary teams from different specialisms when a patient is on more than one treatment pathway.

View full coroner's concerns

The MATTER OF CONCERN is as follows –

• There is little evidence to date of effective communication between Multi-Disciplinary Teams (MDT) from different specialisms when a patient is on more than one treatment pathway.

In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.

Responses

1 respondent

Nottingham University Hospitals NHS Trust

NHS Trust

Indexed date: 18 Jan 2024 PDF

AI-classified response stance Action Planned

AI-generated response summary

• The Trust stated that actions taken or planned in response to the inquest's learning would be summarised. • The delivery of these actions will be overseen by Quality and Safety Governance Committees. • Committees of the Board will receive progress reports on the actions.

View full response

Dear Miss Wood

Inquest: - Michael Daft- Prevention of Future Death Report [PFDR] Response

I am writing in my capacity as Medical Director of Nottingham University Hospitals NHS Trust in response to the Prevention of Future Deaths Notice issued on 24th November 2023 following the sad death of Mr Michael Daft. May I begin with offering my sincerest condolences to Mr Daft’s family for their loss. I am deeply sorry for the missed opportunities and issues that were highlighted during the Inquest. The concerns you have raised have been taken extremely seriously. Please find attached a commentary in response to the Prevention of Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the inquest into the death of Mr Daft. My response to the concerns identified in the PFD report have been informed following work undertaken by colleagues within the Patient Safety Teams, Surgical and Cancer and Associated Specialties (CAS) Divisions and the Cancer Centre Team.

The actions either taken or planned in response to the learning from the inquest are summarised below. The oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight - Committees of our Board will receive a progress report. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust.

Report sections

Investigation and inquest

On the 23rd of November 2022, I commenced an investigation into the death of Michael David Daft. The investigation concluded at the end of the inquest on the 22nd of November 2023. The conclusion of the inquest was natural causes.

Circumstances of the death

Michael was diagnosed with rectal cancer on the 30th of July 2021. A left renal mass was also identified, and further tests had to be undertaken to identify its cause. There were delays in establishing the renal diagnosis and the colorectal surgery was postponed until the outcome of that was known. A diagnosis of renal cell carcinoma was confirmed on the 5th of November 2021 and the necessary surgery for both conditions was planned for the 3rd of December 2021 but was cancelled due to no HDU bed. Further scans identified a progression of the rectal cancer and Michael was referred to Oncology for treatment, which commenced in January 2022. Michael’s cancer did not respond to treatment, and he was admitted to hospital on the 8th of November. He deteriorated rapidly and died on the 10th of November 2022, at City Hospital, Nottingham, from a perforated bowel, secondary to tumour progression. Detailed findings as to how he came by his death are described within a written Determination dated 22nd of November 2023, appended to this report.

Copies sent to

2. The Nottingham University Hospital Trust (NUH)

Similar PFD reports

Shared signals

Report details

Reference: 2023-0475
Date of report: 24 November 2023
Coroner: Sarah Wood
Coroner area: Nottinghamshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 19 Jan 2024 (estimated from the report date).

Sent to

Nottingham University Hospitals NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

Contains public sector information licensed under the Open Government Licence v3.0.