Source · Prevention of Future Deaths

John Higgs

Ref: 2017-0113 Date: 10 Apr 2017 Coroner: Sarah Slater Area: South Yorkshire (West) Responses identified: 1 / 1 View PDF

The system for communicating unexpected, non-cancerous radiological findings is flawed, relying solely on one doctor to notice and input information, with no "red flag" or specific protocol for critical non-cancerous results.

Date 10 Apr 2017

56-day deadline 27 Jun 2017

Responses identified 1 of 1

Other related deaths

Coroner's concerns

AI summary

View full coroner's concerns

The MATTER OF CONCERN for the Secretary of State to consider is as follows:

The inquest heard that the Trust now relies on an electronic system rather than the paper system as it did in 2011. However, any unexpected significant/serious radiological finding are still included in a report that is only sent to the Consultant in charge of the care and it is a matter for that doctor to notice that part of the report and to input this information on the system as a message. In essence, the procedures appear to be the same, it the mode of recording the information that had changed from paper to computer. No other measures have been put in place and the system is still reliant on one doctor noticing and recording the information. In addition, the Court heard there was no facility to place a “red flag” on the system to increase the likelihood of other clinicians being made aware of these unexpected and significant findings.

The Trust has a radiology protocol for “unexpected cancer pathology” where the results are sent to the treating Consultant but also sent to the MDT Cancer Co-ordinator for action but no such protocol exists for non-cancerous but significant and potentially life threatening findings.

The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to “unexpected (non-cancerous) radiological findings because HMAC is concerned that this situation could occur again.

Responses

1 respondent

John higgs

23 Jun 2017 PDF

Action Taken

The Trust will reissue existing Guidance on Communication of Critical or Urgent Radiological Findings to relevant clinical staff who joined after 2016 and disseminate it via a Patient Safety Bulletin. They are also working towards the RCR's Standards for communication of radiological reports. (AI summary)

View full response

Dear Mrs Slater Re: Mr John Higgs dob 23/5/29 (Deceased) am writing in response to your letter dated 10 April 2017 sent to me under the provisions of Regulation 28 of the Coroner's Investigation Regulations 2013, relating to the inquest of Mr John Higgs held on April 2017 . am grateful for your letter as this has highlighted an area within the Trust in which patient care and safety can be improved. On 20 April 2017 a meeting took place betweer Interim Medical Director Deputy Medical Director, Head of Radiology; and General Manager responsible for Radiology and Interim Trust Solicitor to review your letter and discuss the actions and response to your concerns in Part 5 of the Regulation
28. Taking each paragraph in turn of HM Coroner's Concerns at Part 5: Paragraphs _ and 2 At the meeting on 20 April 2017 it was established that there is in fact already in existence guidance which covers unexpected or urgent findings and communication of critical or urgent unexpected significant radiological findings. This is called Guidance on Communication of Critical or Urgent or www barnsleyhospitalnhs uk ebarnshospital www facebook com/barnsleyhospital MC

Unexpected Significant Radiological Findings ("Guidance") It is unfortunate that this did not come to light at the recent inquest: apologise to you and to Mr Higgs's family: We will ensure that the Guidance is re-issued to the relevant clinical staff who have joined our organisation after 2016. We have included the Guidance as the basis of the Patient Safety Bulletin. In addition, the policy and Regulation 28 response will be reviewed and disseminated at the quarterly Quality and Governance Committee which is attended by senior medical nursing and managerial staff:. By way of background the Guidance came in to existence on 16 January 2012 (EXH and IA) and was completely re-written and comprehensively updated in October 2015 by In line with Trust policy review requirements, this document has been re-reviewed and minor changes made in July 2016 (EXH 3) The versions of the Guidance from January 2012 to date are enclosed and for your information and consideration. The Guidance essentially sets out in detail to report incidental radiological findings and in what manner this should be achieved, this local Guidance accords with the Royal College of Radiologists ("RCR") standards for fail safe alert systems documentation which was published in
2016. HM Coroner's attention is kindly drawn to page 10, Paragraph 4(B) of the guidance. confirms the combination of the new Guidance, advice sought and the electronic reporting systems (ICE) now in place would significantly reduce the risk of a similar incident occurring in the future_ The radiologist would be able to up a serious incidental finding to the treating clinician for their prompt action_ Paragraph 3 Barnsley Hospital NHS Foundation Trust has reviewed its processes for interpretation and communication of serious but incidental findings, and has considered its processes which are set out above_ It is acknowledged throughout the NHS nationally that there is a problem We have made contact with other local NHS Trusts and been advised that the prompt review and actioning of the result by clinician's is however an area which may require improvement: The above Guidance in line with Royal College of Radiologist standards, improved significantly the reporting of incidental findings. We firmly believe that the measures that we have put in place will significantly reduce the likelihood of future deaths_ As Trust we realise human error is a factor in many of our processes we manage those by introducing policies and systems to minimise incidents of this nature occurring: It is clear following our enquires that the potential for human error remains an issue for all NHS Trusts_ Results acknowledgement andlor action is not a local problem unique to Barnsley (or is it unique to the NHS) It is a global issue for which various different methods have been used to try and resolve the problem: Such methods have spanned from using third party applications to administer the two way acknowledgement process (Christchurch Hospital, New Zealand) through to changes in

how May flag has,

legislation making it a legal duty of the requesting clinician to acknowledge and act on test results (Ireland and the US) The NHS has neither the resource and technical uniformity to make an electronic workflow fool-proof and does not have a track record of taking action in clear failures of NPSA 16. There is plenty of commentary online a couple samples have been selected (and are enclosed) for HM Coroners ease of reference below: http:IIww pacsgrouporg Uklforumlmessages/2/79236.html (EXH 4) bttps IIWw_rcr_ac Uklpostslpatients-risk-lack-systems-communicating-abnormal-imaging-test results (EXH 5) In addition RCR's Standards for the communication of radiological reports and fail-safe alert notification (2016) which contains 10 recommended standards, and which the Trust is working towards_ httpsIwww rcr acuklsystemlfileslpublicationlfield publication fileslbfcr164_failsafe pdf (EXH 6). The Trust has asked the NHS Benchmarking Network to consider compliance with implementation of the standards in this years census hope that the above reassures HM Coroner and the family that whilst the communication of incidental radiological results, and those outside cancer pathologies remains a problem nationally, that the use of ICE and our Guidance will work in tandem to greatly reduce the risk of a future death like Mr Higgs' from occurring again at our hospital. If | can be of further assistance please do not hesitate to contact me_

Report sections

Investigation and inquest

On 22nd December 2016 I commenced an investigation into the death of Mr John Higgs. The investigation concluded at the end of the inquest on 7th April 2017. The conclusion of the inquest was that Mr Higgs died from 1(a) Ruptured Abdominal Aortic Aneurysm
2. Stroke, Frailty of old age A narrative conclusion was recorded as follows: Mr Higgs died in Barnsley General Hospital on the 18th November 2015 as a result of a ruptured abdominal aortic aneurysm. In March 2011, Mr Higgs attended Barnsley General Hospital and underwent a CT scan which identified the presence of a 6cm abdominal aortic aneurysm. This finding was not communicated to Mr Higgs despite him attending at the hospital on a number of occasions following the scan. In addition, the general practitioner was not informed therefore Mr Higgs was not referred to specialist vascular surgeons and he did not have the opportunity to consider any further treatment options prior to his sudden collapse in 2015.

Circumstances of the death

Mr Higgs attended Barnsley General Hospital on the 18th November 2015 following a fall and vacant episode. It was initially though that Mr Higgs had suffered a further stroke but an ultrasound scan revealed a 6.6cm abdominal aortic aneurysm which was leaking. He Higgs died later that same day. After Mr Higgs death, his wife received the death certificate and sent a letter to the hospital asking why she had not been informed that he husband had an aneurysm. This was investigated by the Trust and it was found that Mr Higgs had undergone a CT scan in March 2011 and the scan had identified the presence of a 6cm abdominal aortic aneurysm but the results had been overlooked at the time and therefore not communicated to Mr Higgs, other clinicians or his general practitioner. The evidence at the inquest was that presence of the abdominal aortic aneurysm was an unexpected finding on the CT scan. The report had been seen by the Consultant Surgeon in charge of the care, but he did not act upon these results because Mr Higgs was attending clinic 5 days later and therefore the Consultant would discuss them with the patient. At this time, the trust relied on paper records. Mr Higgs attended clinic and was seen by a junior doctor who either did not review the CT report or it was unavailable because it was still with the consultant awaiting filing on the patient records. There was no evidence in court of a safe system of communication at the time (2011). Mr Higgs attended at the hospital on a number of occasions after the scan results were available in 2011 and was seen by several different doctors but the CT scan results from 2011 were not looked at. In addition, the general practitioner was not informed therefore Mr Higgs was not referred to specialist vascular surgeons and he did not have the opportunity to consider any further treatment options prior to his sudden collapse in 2015.

Inquest conclusion

Mr Higgs died in Barnsley General Hospital on the 18th November 2015 as a result of a ruptured abdominal aortic aneurysm. In March 2011, Mr Higgs attended Barnsley General Hospital and underwent a CT scan which identified the presence of a 6cm abdominal aortic aneurysm. This finding was not communicated to Mr Higgs despite him attending at the hospital on a number of occasions following the scan. In addition, the general practitioner was not informed therefore Mr Higgs was not referred to specialist vascular surgeons and he did not have the opportunity to consider any further treatment options prior to his sudden collapse in 2015.

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Report details

Reference: 2017-0113
Date of report: 10 April 2017
Coroner: Sarah Slater
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: 27 Jun 2017.

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.