Source · Prevention of Future Deaths

Elizabeth Self

Ref: 2018-0308 Date: 29 Oct 2018 Coroner: Christopher Dorries Area: South Yorkshire (West) 1 response identified · 1 indexed addressee View PDF

AI-generated concerns summaryThe coroner identified a lack of training for moderately senior doctors in making X-ray requests and the risk of CT requests remaining unattended for extended periods due to communication breakdowns, leading to significant delays in completing investigations.

Date 29 Oct 2018

56-day deadline 15 Jan 2019 stated in the report

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The coroner identified a lack of training for moderately senior doctors in making X-ray requests and the risk of CT requests remaining unattended for extended periods due to communication breakdowns, leading to significant delays in completing investigations.

View full coroner's concerns

am satisfied that the hospital in question has taken appropriate and significant remedial action and do not therefore find it necessary to address this report to the hospital itself: However; my concern is that this situation can arise elsewhere which is why address this report to NHS England: as set out in my closing remarks (attached), that is to say a) moderately senior doctor had put in not one but two X-ray requests that had to be rejected which is suggestive of a lack of necessary training b) A valid CT request had laid unattended for a full morning, the reasons for which were never established but the hospitals own investigation report team formed an impression of a breakdown in communications_ c) The overall circumstances were such that neither requests was actually completed until more than thirteen hours after what was a significant fall: The inquest found this to be a criticism of the system then in place rather than of particular individuals. In essence my concern is that those inspecting hospitals in other places should include in their programme establishing that senior staff do actually know how to make a proper X-ray request which will not therefore be rejected and checking systems to ensure that X-ray and CT requests cannot go for a period of hours without resolution:

Responses

1 respondent

NHS England

NHS / Health Body

Indexed date: 30 Oct 2018 PDF

AI-classified response stance Action Planned

AI-generated response summary

• NHS England has been working with hospitals to improve standards of care, including access to appropriate diagnostic imaging, through the seven-day services programme. • NHS England will ensure the learning from this matter is disseminated through quality structures across England.

View full response

Dear Mr Dorries Regulation 28 report in relation to Mrs Elizabeth Glen Self (deceased) write in response to the above report sent to NHS England on 30th October 2018. Firstly, would like to apologise to the family of Mrs Self and yourself for the delay in this response. Whilst it is not an excuse_ we have been in period of significant organisational change and this has delayed the response would like to offer my condolences to the family of Mrs Self and apologise for any added distress this has caused. note that you have been satisfied that the trust has ensured appropriate learning has been taken to ensure this situation does not arise again. You have asked NHS England and Improvement to ensure that those inspecting hospitals should ensure gain assurance that senior staff are aware of the appropriate process and method to request urgent radiology requests and that trusts have a process in place to ensure urgent requests are reviewed in a timely manner_ Inspection of hospitals is undertaken by the Care Quality Commission (CQC) and note have received a copy of the notice: The CQC's regulatory function is independent of NHS Englandllmprovement, so am not in position to require response from them in relation to this matter. NHS Englandllmprovement have however been working with hospitals to improve standards of care provided to patients under the day services programme: This includes ready access to appropriate diagnostic imaging which would be relevant to this case_ Further details of this programme can be found at https llimprovement nhs uk/resourceslseven-day_servicesltth2-the-four-priority-standards NHS England and Improvement has responsibility for quality oversight and assurance and will ensure this matter: and the learning that can be taken it is disseminated through quality structures across England.

Report sections

Investigation and inquest

In November 2017 commenced an investigation into the death of Mrs Elizabeth Glen Self. The investigation concluded following an inquest in June 2018 where the narrative conclusion set out that: Mrs Self was admitted to hospital on 11th April 2017 following a heart attack: The court finds it more likely than not the she would have survived this episode. Unfortunately Mrs Self suffered a serious fall in hospital when she became entangled in a line attached to her left this left her with serious injuries which were not immediately recognised. Necessary scans and X-ray examinations were ordered some hours later but did not take place for another nine hours Or SO. The court has closely considered these most regrettable delays but the expert advice is that a faster response either in investigation or transfer to Sheffield would probably have saved Mrs Self' $ life:

Circumstances of the death

The circumstances of the death are set out in the narrative conclusion shown above. In addition attach a copy of my closing remarks which is just a single sheet In summary, this lady with severe heart disease suffered a fall in hospital. She was unlikely to survive from that onwards but there was a in dealing with two X-ray requests and one CT request of more than thirteen hours_ being leg, not point delay

Action should be taken

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

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Shared signals

Report details

Reference: 2018-0308
Date of report: 29 October 2018
Coroner: Christopher Dorries
Coroner area: South Yorkshire (West)

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: 15 Jan 2019 (stated in the report).

Sent to

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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