paliben dullabh
Action Planned
The Trust disputes the necessity of an external x-ray service due to existing clinician training and on-call radiologists. However, they are implementing a new surgical staffing model within three months and will provide on-call consultants with remote access to review x-rays from home. (AI summary)
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Dear Assistant Coroner Bourke, Re: Paliben Dullabh (deceased) Regulation 28, Prevention of Future Deaths Report on behalf of Homerton University Hospitals NHS Foundation Trust.
I am writing in response to your Regulation 28 Prevention of Future Deaths report of 11 December 2018 received by the Trust on 11 February 2019 regarding the death of Ms Paliben Dullabh.
Your concern: Whilst the Hospital has arrangements in place to obtain out of hours reports from radiologists in relation to CT and MRI scans, there is no similar arrangement for x-rays.
Trust's Response: The evidence provided at the inquest by the Clinical Fellow was that the Consultant had advised him to obtain an opinion from the Trust's contracted out of hours service for MRI and CT imaging. The Trust has considered the concern raised by the Assistant Coroner and responds as follows: It is correct that the out-of-hours provider is not contracted to review x-rays. However, this was a deliberate decision taken by the Trust because it was felt that measures were already in place to ensure that any abnormal x-rays could be identified. These measures are as follows:
a) As part of their training, clinicians are taught to interpret x-rays and identify any imaging that is grossly abnormal and could require urgent intervention. X-rays often take several hours to be reported, even within normal working hours, and so doctors are accustomed to reviewing imaging and do not always need to rely on a radiologist. b) If there is any doubt about whether an x-ray is normal or not outside normal working hours, there is always a Consultant Radiologist on call and doctors are able to contact him/her for further advice along with also consulting with senior colleagues within their own speciality.
Trust Offices Incorporating hospital and community health services, teaching and research
Page 1
The Trust notes that, in the case of Ms Dullabh, the radiographer who escorted her back to the ward after the x-ray did recognise that there was a concern and directly communicated this to the Clinical Fellow who agreed with their diagnosis of perforation. The diagnosis was therefore made without the need for involvement from any out-of-hours service. The Consultant who requested a review of the imaging by the outsourced service was not aware at the time that they do not provide out of hours services. He requested this review to confirm the diagnosis but this was not to be an action that halted other preparations for emergency surgery to take place.
Actions taken: This case highlighted that there was an issue with surgical doctor cover at night and more resources were required to ensure safer staffing levels. The Trust had already committed to addressing this and is in the process of implementing a solution.
In order to comply with BMA guidance in changing workplace practices, this proposal is currently in consultation with the junior doctors and an implementation is expected within the next 3 months. The new model will have substantively appointed registrars rotating through night duty which will enhance governance, consistency of practice and resilience of the cover. In addition, there will be an Senior House Officer (SHO) on duty too which will give another level of support and ensure that delays in reviewing patients should no longer be an issue and test results can be chased up in a more timely manner.
Should the doctors still require assistance out of hours with x-ray imaging, the surgical department will now have a designated lap top within the department that will be taken home by the on-call Consultant. They will have access to all Trust systems including imaging and therefore, if a second opinion is required, the Consultant can review this securely at home and provide advice, or attend if necessary.
We hope that this response reassures you that the Trust has reviewed this case and has made improvements to prevent this situation arising again..
Please do not hesitate to contact us if you would like to discuss anything mentioned in this response.
I am writing in response to your Regulation 28 Prevention of Future Deaths report of 11 December 2018 received by the Trust on 11 February 2019 regarding the death of Ms Paliben Dullabh.
Your concern: Whilst the Hospital has arrangements in place to obtain out of hours reports from radiologists in relation to CT and MRI scans, there is no similar arrangement for x-rays.
Trust's Response: The evidence provided at the inquest by the Clinical Fellow was that the Consultant had advised him to obtain an opinion from the Trust's contracted out of hours service for MRI and CT imaging. The Trust has considered the concern raised by the Assistant Coroner and responds as follows: It is correct that the out-of-hours provider is not contracted to review x-rays. However, this was a deliberate decision taken by the Trust because it was felt that measures were already in place to ensure that any abnormal x-rays could be identified. These measures are as follows:
a) As part of their training, clinicians are taught to interpret x-rays and identify any imaging that is grossly abnormal and could require urgent intervention. X-rays often take several hours to be reported, even within normal working hours, and so doctors are accustomed to reviewing imaging and do not always need to rely on a radiologist. b) If there is any doubt about whether an x-ray is normal or not outside normal working hours, there is always a Consultant Radiologist on call and doctors are able to contact him/her for further advice along with also consulting with senior colleagues within their own speciality.
Trust Offices Incorporating hospital and community health services, teaching and research
Page 1
The Trust notes that, in the case of Ms Dullabh, the radiographer who escorted her back to the ward after the x-ray did recognise that there was a concern and directly communicated this to the Clinical Fellow who agreed with their diagnosis of perforation. The diagnosis was therefore made without the need for involvement from any out-of-hours service. The Consultant who requested a review of the imaging by the outsourced service was not aware at the time that they do not provide out of hours services. He requested this review to confirm the diagnosis but this was not to be an action that halted other preparations for emergency surgery to take place.
Actions taken: This case highlighted that there was an issue with surgical doctor cover at night and more resources were required to ensure safer staffing levels. The Trust had already committed to addressing this and is in the process of implementing a solution.
In order to comply with BMA guidance in changing workplace practices, this proposal is currently in consultation with the junior doctors and an implementation is expected within the next 3 months. The new model will have substantively appointed registrars rotating through night duty which will enhance governance, consistency of practice and resilience of the cover. In addition, there will be an Senior House Officer (SHO) on duty too which will give another level of support and ensure that delays in reviewing patients should no longer be an issue and test results can be chased up in a more timely manner.
Should the doctors still require assistance out of hours with x-ray imaging, the surgical department will now have a designated lap top within the department that will be taken home by the on-call Consultant. They will have access to all Trust systems including imaging and therefore, if a second opinion is required, the Consultant can review this securely at home and provide advice, or attend if necessary.
We hope that this response reassures you that the Trust has reviewed this case and has made improvements to prevent this situation arising again..
Please do not hesitate to contact us if you would like to discuss anything mentioned in this response.