Barking, Havering and Redbridge University Hospitals NHS Trust
NHS / Health Body
Action Planned
Barking, Havering and Redbridge University Hospitals NHS Trust will alert referrers to all imaging with expected, unexpected, or newly detected cancer, and critical non-cancer findings, with actions tracked in a version-controlled action plan. They will develop and implement a Standard Operating Procedure (SOP) for radiological findings of cancer, as well as a SOP for lung nodules identified as an incidental finding. (AI summary)
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Dear
The concerns of HM Coroner are recognised and have been considered. This response will describe actions that are proposed or those that have already been taken to prevent future deaths by addressing the concerns set out below. This response has been devised using the Principles and Recommendations of a Fail-Safe Result Notification System1 as reference with input from the Radiology Leadership Team.
A version-controlled Action Plan will be developed, tracked, and communicated so that all actions are SMART, coordinated, prioritised, and shared with key stakeholders.
Concern 1: The Trust’s new policy is concerned with ensuring that unexpected cancer or other critical radiological findings are highlighted to the requesting team. However, the evidence at the inquest suggested that requesting team were not alerted to the suspicious outcome of the Deceased’s November 2020 scan because it was an expected finding; as stated above, I was told that the radiologist’s report was not escalated or alerted to the clinical or multi-disciplinary teams because the requesting form had indicated that the scan was to rule out malignancy and the outcome was not, therefore, treated as unexpected. I am concerned, therefore, that the same could happen again, despite the changes which have been made. I did not consider that was able to address this concern satisfactorily in his evidence.
1. The Radiology department will alert/notify the referrer’s/requesters to all imaging with:
a. Expected, Unexpected, or Newly Detected Cancer
b. Unexpected Critical or Significant Non-Cancer Findings. The referrer/requester will be notified with either a CANCER alert for the expected, unexpected, or newly detected cancer and cancer recurrence, or CRITICAL alert for expected or unexpected findings. This will be sent electronically via Aptvision2 to the referrer/requester (*Verbal Escalation is required when there is an Emergency Critical Finding <1 hour). This will be irrespective of patient type i.e., Inpatient, Outpatient or if the Patient is on a Cancer or Urgent Pathway. In May of this year (2023) the Radiology Unsuspected Cancers and Critical Findings Protocol – BHRUT - Version 83 was reviewed and updated to reflect this change in process. This was communicated to all Consultants in the Trust by the Clinical Lead for Radiology via email (17 May
2023) with a second communication detailing the change sent by the Chief Medical Officer (02 June 2023).
Concern 2: The new electronic system is introducing a “read receipt” feature which, if used, would enable identification of reports which have not been opened and read by the requesting team in a timely manner. I am concerned, however, that the use of the read receipt is optional as this will inevitably undermine the extent to which any monitoring system will be able to spot and identify unread reports. I did not consider that either , or the Consultant Colorectal Surgeon from whom I heard evidence about the plans for monitoring in the surgical department of Queens Hospital, were able to address this concern satisfactorily in their evidence.
It is the responsibility of the requesting doctor and/or their clinical team to read and act upon the report findings and fail-safe alerts as quickly and efficiently as possible. This extends to ensuring robust mechanisms are in place and resourced to cover leave within clinical teams or practices.
1. Aptvison Radiology Referral System – this new Radiology Requesting System is planned to live week commencing 30 October 2023.
2. Acknowledgement Feature – Following a finalised radiological report, alongside any urgent notifications produced by radiology, an “acknowledgment” button is available. The “acknowledgment” button functionality allows all referrers involved in the initial radiology request to electronically select and acknowledge the receipt of the patient’s radiological report. The referral portal4 training material and learning outcomes for users, will emphasise the requirement of acknowledging results.
3. Viewable WorkLists – It is planned that a viewable worklist of requested imaging and radiological report by referring location /area will be available in the initial release of the referral portal. A secondary release is planned to allow consultants/referrers to view a worklist based who was involved in the requesting process
e.g., individual consultant or a group of named team members.
4. Oversight of Reporting - Speciality Specific Reports – Requesting Specialties will be provided with direct access to Business Information (BI) reports summarising a list of patients for whom results have not been acknowledged by the requesting clinician. Once access has been provided, each of the Clinical Groups (CGs) will use the information for local discussion and management through their own Governance/ Quality and Safety meetings. A fortnightly status update will be produced and fed back to each of the CGs/ Specialties highlighting those reports that have not been read at 7 days. It is anticipated that the SitRep will include:
• The average time of review.
• Reports that have not been read and by whom.
• Requesting numbers
• Any rejected scans or not completed scans and the reason why. Areas with high locum usage across the Trust will be identified and the responsible CGs will locally assess the potential clinical risk of having a transient workforce. The CGs will be expected to understand and articulate if there is a risk to clinical care and to ensure mitigation is in place to eliminate this risk.
5. Speciality Specific Mailboxes – will be created by the Specialties. This is as an additional safeguard where the notification of imaging report will be sent to a group email in addition to the named consultants individual worklist. Access to shared mailbox will be agreed by the Specialty.
6. Chief Medical Officer Message - To facilitate prompt review, acknowledgement, and action on all imaging reports by referrers. The CMO (or nominated deputy) will inform each CG of the requirement that each of the
Specialties within their CG must identify within the specialty teams who the reports will be sent to. This must include Consultant responsible and key Personnel e.g., secretary/Multi-Disciplinary Team (MDT)/Patient Pathway Manager (PPM) and Clinical Nurse Specialist (CNS), this will be decided by each speciality. Consideration of annual leave/sickness and staff turnover will be included.
The Radiological Requesting, Review and Expectation process as detailed in this response will be added to the New Consultants 3-day Induction programme run by the CMO.
7. Collaborative Working - On 04 July 2023 Dr Ghadge, Consultant Radiologist and Clinical Lead for Radiology, presented the BHRUT’s Policy on Incidental Finding at the North-East London (NEL) Clinical Leadership Group for peer review. This group’s membership comprises of the Quality and Safety Leads (Consultant grade) from Whipps Cross Hospital, St Bartholomew Hospital, the Royal London Hospital, the Homerton and Newham Hospital. The progress made by BHRUT was recognised and the group members agreed to devise a Unified Incidental Finding Policy across NEL. At the last meeting (01 September 2023), it was agreed that a policy for Cancer Alerts would be developed whereas Critical non-cancer alerts would vary as per local needs. The next meeting planned is 01 December 2023. References
1. Alerts and Notification of Imaging Reports. Recommendations. Academy of Medical Royal Colleges. October
2022. (Document to be added to response).
2. At BHRUT the electronic web based, integrated Radiology Information System (RIS) from Aptvision provides a platform for verifying appropriateness of requests for radiology investigations, protocoling radiology examinations to answer the clinical question, booking the exam and recording the report of radiology exams. It can also be used to share vetting responsibility across the teams where the priority of a request upgraded to a more urgent based on the clinical history provided by the clinical team. The different steps of this process are visible to all referring doctors creating greater visibility of requests and where they are in the process.
3. Radiology Unsuspected Cancers and Critical Findings Protocol. BHRUT. Version 8. May 2023. (Document to be added to response).
4. As a Trust we are working towards providing an Electronic Requesting Portal for Radiology. This digital platform will facilitate a digital means for clinicians/referrers to electronically request radiological imaging within the Trust. Referrers can then easily track the status of their referrals through various stages i.e., Vetting, registered, examined, all the way to reported and can also communicate bi-directionally to convey more information, cancellation reasons and alternative imaging changes. All the previously mentioned communications constitute are reflected as “Alerts” which will be displayed on a dedicated page within the portal. There is also the capability for results to be acknowledged by, you as a refer or responsible episode consultant have read the report the findings. Additional documents (to be added to response)
5. Solitary Pulmonary Nodule Clinic Standard Operating Procedure (SOP). This document has been included to provide further assurance to HM Coroner regarding the management of lung nodules highlighted as an incidental finding. This process was approved after the Serious Incident and demonstrates that there is process in the Trust for the management of Incidental Findings of nodules.
6. Presentation to NEL Peers 04 July 2023 at the North-East London Clinical Leadership Group meeting
7. Agenda for the North-East London Clinical Leadership Group meeting on 01 September 2023.
8. Action Plan.
Further Information: The demand for Diagnostic and Intervention Radiology at Barking, Havering and Redbridge University Trust (BHRUT) continues to grow with 535,000 radiology requests received in the last financial year 2022-2023 and 363,664 so far this year to date. Figure 1 – Radiology Requests from 2018 – 2023 (current)
Sum of EXAMS by Imaging Modality Year CT Fluoro- scopy MRI Non obstetric US Obstetric US Radio no Fluoro Radio- Isotopes Grand Total 2018 60,750 10,749 38,478 120,756 54,513 277,475 6,802 569,523 2019 64,715 10,521 43,546 127,450 61,779 279,465 6,705 594,181 2020 61,673 8,494 33,733 80,181 50,570 214,777 4,405 453,833 2021 76,488 9,326 38,738 89,535 58,335 251,912 5,372 529,706 2022 81,942 9,767 45,984 96,184 63,763 259,147 5,961 562,748 2023 50,222 6,216 29,036 73,903 38,077 162,533 3,677 363,664 Grand Total 395,790 55,073 229,515 588,009 327,037 1,445,309 32,922 3,073,655
This places huge demand on this service and across the wider Trust (e.g., urgent radiological referrals for Cancer diagnosis and Cancer management, Outpatient GP referrals and Emergency Department imaging). A Trust wide approach is required to ensure that a robust reporting system is in place.
The concerns of HM Coroner are recognised and have been considered. This response will describe actions that are proposed or those that have already been taken to prevent future deaths by addressing the concerns set out below. This response has been devised using the Principles and Recommendations of a Fail-Safe Result Notification System1 as reference with input from the Radiology Leadership Team.
A version-controlled Action Plan will be developed, tracked, and communicated so that all actions are SMART, coordinated, prioritised, and shared with key stakeholders.
Concern 1: The Trust’s new policy is concerned with ensuring that unexpected cancer or other critical radiological findings are highlighted to the requesting team. However, the evidence at the inquest suggested that requesting team were not alerted to the suspicious outcome of the Deceased’s November 2020 scan because it was an expected finding; as stated above, I was told that the radiologist’s report was not escalated or alerted to the clinical or multi-disciplinary teams because the requesting form had indicated that the scan was to rule out malignancy and the outcome was not, therefore, treated as unexpected. I am concerned, therefore, that the same could happen again, despite the changes which have been made. I did not consider that was able to address this concern satisfactorily in his evidence.
1. The Radiology department will alert/notify the referrer’s/requesters to all imaging with:
a. Expected, Unexpected, or Newly Detected Cancer
b. Unexpected Critical or Significant Non-Cancer Findings. The referrer/requester will be notified with either a CANCER alert for the expected, unexpected, or newly detected cancer and cancer recurrence, or CRITICAL alert for expected or unexpected findings. This will be sent electronically via Aptvision2 to the referrer/requester (*Verbal Escalation is required when there is an Emergency Critical Finding <1 hour). This will be irrespective of patient type i.e., Inpatient, Outpatient or if the Patient is on a Cancer or Urgent Pathway. In May of this year (2023) the Radiology Unsuspected Cancers and Critical Findings Protocol – BHRUT - Version 83 was reviewed and updated to reflect this change in process. This was communicated to all Consultants in the Trust by the Clinical Lead for Radiology via email (17 May
2023) with a second communication detailing the change sent by the Chief Medical Officer (02 June 2023).
Concern 2: The new electronic system is introducing a “read receipt” feature which, if used, would enable identification of reports which have not been opened and read by the requesting team in a timely manner. I am concerned, however, that the use of the read receipt is optional as this will inevitably undermine the extent to which any monitoring system will be able to spot and identify unread reports. I did not consider that either , or the Consultant Colorectal Surgeon from whom I heard evidence about the plans for monitoring in the surgical department of Queens Hospital, were able to address this concern satisfactorily in their evidence.
It is the responsibility of the requesting doctor and/or their clinical team to read and act upon the report findings and fail-safe alerts as quickly and efficiently as possible. This extends to ensuring robust mechanisms are in place and resourced to cover leave within clinical teams or practices.
1. Aptvison Radiology Referral System – this new Radiology Requesting System is planned to live week commencing 30 October 2023.
2. Acknowledgement Feature – Following a finalised radiological report, alongside any urgent notifications produced by radiology, an “acknowledgment” button is available. The “acknowledgment” button functionality allows all referrers involved in the initial radiology request to electronically select and acknowledge the receipt of the patient’s radiological report. The referral portal4 training material and learning outcomes for users, will emphasise the requirement of acknowledging results.
3. Viewable WorkLists – It is planned that a viewable worklist of requested imaging and radiological report by referring location /area will be available in the initial release of the referral portal. A secondary release is planned to allow consultants/referrers to view a worklist based who was involved in the requesting process
e.g., individual consultant or a group of named team members.
4. Oversight of Reporting - Speciality Specific Reports – Requesting Specialties will be provided with direct access to Business Information (BI) reports summarising a list of patients for whom results have not been acknowledged by the requesting clinician. Once access has been provided, each of the Clinical Groups (CGs) will use the information for local discussion and management through their own Governance/ Quality and Safety meetings. A fortnightly status update will be produced and fed back to each of the CGs/ Specialties highlighting those reports that have not been read at 7 days. It is anticipated that the SitRep will include:
• The average time of review.
• Reports that have not been read and by whom.
• Requesting numbers
• Any rejected scans or not completed scans and the reason why. Areas with high locum usage across the Trust will be identified and the responsible CGs will locally assess the potential clinical risk of having a transient workforce. The CGs will be expected to understand and articulate if there is a risk to clinical care and to ensure mitigation is in place to eliminate this risk.
5. Speciality Specific Mailboxes – will be created by the Specialties. This is as an additional safeguard where the notification of imaging report will be sent to a group email in addition to the named consultants individual worklist. Access to shared mailbox will be agreed by the Specialty.
6. Chief Medical Officer Message - To facilitate prompt review, acknowledgement, and action on all imaging reports by referrers. The CMO (or nominated deputy) will inform each CG of the requirement that each of the
Specialties within their CG must identify within the specialty teams who the reports will be sent to. This must include Consultant responsible and key Personnel e.g., secretary/Multi-Disciplinary Team (MDT)/Patient Pathway Manager (PPM) and Clinical Nurse Specialist (CNS), this will be decided by each speciality. Consideration of annual leave/sickness and staff turnover will be included.
The Radiological Requesting, Review and Expectation process as detailed in this response will be added to the New Consultants 3-day Induction programme run by the CMO.
7. Collaborative Working - On 04 July 2023 Dr Ghadge, Consultant Radiologist and Clinical Lead for Radiology, presented the BHRUT’s Policy on Incidental Finding at the North-East London (NEL) Clinical Leadership Group for peer review. This group’s membership comprises of the Quality and Safety Leads (Consultant grade) from Whipps Cross Hospital, St Bartholomew Hospital, the Royal London Hospital, the Homerton and Newham Hospital. The progress made by BHRUT was recognised and the group members agreed to devise a Unified Incidental Finding Policy across NEL. At the last meeting (01 September 2023), it was agreed that a policy for Cancer Alerts would be developed whereas Critical non-cancer alerts would vary as per local needs. The next meeting planned is 01 December 2023. References
1. Alerts and Notification of Imaging Reports. Recommendations. Academy of Medical Royal Colleges. October
2022. (Document to be added to response).
2. At BHRUT the electronic web based, integrated Radiology Information System (RIS) from Aptvision provides a platform for verifying appropriateness of requests for radiology investigations, protocoling radiology examinations to answer the clinical question, booking the exam and recording the report of radiology exams. It can also be used to share vetting responsibility across the teams where the priority of a request upgraded to a more urgent based on the clinical history provided by the clinical team. The different steps of this process are visible to all referring doctors creating greater visibility of requests and where they are in the process.
3. Radiology Unsuspected Cancers and Critical Findings Protocol. BHRUT. Version 8. May 2023. (Document to be added to response).
4. As a Trust we are working towards providing an Electronic Requesting Portal for Radiology. This digital platform will facilitate a digital means for clinicians/referrers to electronically request radiological imaging within the Trust. Referrers can then easily track the status of their referrals through various stages i.e., Vetting, registered, examined, all the way to reported and can also communicate bi-directionally to convey more information, cancellation reasons and alternative imaging changes. All the previously mentioned communications constitute are reflected as “Alerts” which will be displayed on a dedicated page within the portal. There is also the capability for results to be acknowledged by, you as a refer or responsible episode consultant have read the report the findings. Additional documents (to be added to response)
5. Solitary Pulmonary Nodule Clinic Standard Operating Procedure (SOP). This document has been included to provide further assurance to HM Coroner regarding the management of lung nodules highlighted as an incidental finding. This process was approved after the Serious Incident and demonstrates that there is process in the Trust for the management of Incidental Findings of nodules.
6. Presentation to NEL Peers 04 July 2023 at the North-East London Clinical Leadership Group meeting
7. Agenda for the North-East London Clinical Leadership Group meeting on 01 September 2023.
8. Action Plan.
Further Information: The demand for Diagnostic and Intervention Radiology at Barking, Havering and Redbridge University Trust (BHRUT) continues to grow with 535,000 radiology requests received in the last financial year 2022-2023 and 363,664 so far this year to date. Figure 1 – Radiology Requests from 2018 – 2023 (current)
Sum of EXAMS by Imaging Modality Year CT Fluoro- scopy MRI Non obstetric US Obstetric US Radio no Fluoro Radio- Isotopes Grand Total 2018 60,750 10,749 38,478 120,756 54,513 277,475 6,802 569,523 2019 64,715 10,521 43,546 127,450 61,779 279,465 6,705 594,181 2020 61,673 8,494 33,733 80,181 50,570 214,777 4,405 453,833 2021 76,488 9,326 38,738 89,535 58,335 251,912 5,372 529,706 2022 81,942 9,767 45,984 96,184 63,763 259,147 5,961 562,748 2023 50,222 6,216 29,036 73,903 38,077 162,533 3,677 363,664 Grand Total 395,790 55,073 229,515 588,009 327,037 1,445,309 32,922 3,073,655
This places huge demand on this service and across the wider Trust (e.g., urgent radiological referrals for Cancer diagnosis and Cancer management, Outpatient GP referrals and Emergency Department imaging). A Trust wide approach is required to ensure that a robust reporting system is in place.