Source · Prevention of Future Deaths

Karen Thorne

Ref: 2016-0408 Date: 11 Nov 2016 Coroner: Alan Walsh Area: Manchester (West) Responses identified: 1 / 1 View PDF

Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an increase in training positions.

Date 11 Nov 2016

56-day deadline 6 Jan 2017 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Severe delays in neuroradiology reporting due to a national radiologist shortage prevent timely diagnosis and treatment, necessitating an increase in training positions.

View full coroner's concerns

1. During the Inquest evidence was heard that:- There are delays_in reporting neuroradiology within the Salford Royal NHS Foundation Trust and at the present time the longest wait is 60 days, which is a slight improvement from the end of 2015 when the Scan conducted on the Deceased was not reported for 65 days but a of 60 days is still unacceptable: ii_ There is an increasing demand for neuroradiology, and radiology in general, and there is a national shortage of Radiologists.
iii. The in reporting radiology is of greater concern in cases where a patient is receiving treatment on regular basis, namely in the case of the Deceased, ad the Scans are not reported for a period in excess of 60 working during which time the Deceased received 2 or 3 additional Natalizumab infusions, which would have been stopped had the Scan been reported and identified PML before the next infusion:
iv. Evidence was given at the Inquest, on the basis of information received from the Royal College of Radiologists, that the national shortage of Radiologists was due to the fact that there are a fixed number of training positions for Radiologists each year ad the number is insufficient to produce the number of Radiologists required to give an appropriate service and to report radiology within reasonable, necessary and expected period: The information referred to the fact that there was no shortage of clinicians prepared to train as Radiologists and that there were more applicants than training positions: May delay the the delay delay days every days, time

The evidence given to the Inquest was that an increase in the number of training positions would increase the number of Radiologists to address the national shortage of Radiologists, which is creating the delays in reporting radiology and delays in the diagnosis of conditions requiring either immediate treatment or the cessation of treatment with recognised complications; I request you to consider the above concerns in relation to national shortage of Radiologists and to review the number of training positions to address national shortage of Radiologists and to address delays in the reporting of radiology and the diagnosis of disease, either requiring treatment or the cessation of treatment:

Responses

1 respondent

Department of Health Central Government

24 Jan 2017 PDF

Action Planned

Health Education England is working in partnership to develop a shared vision and strategy for the diagnostics workforce and is committed to recruiting more trainees into diagnostics, including radiologists. (AI summary)

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Philip Dunne MP Minister of State for Health Department of Health RECEIVED Richmond House 79 Whitehall Mr Alan P Walsh 2 6 JAN 2017 London Area Coroner Manchester West SWIA 2NS HM Coroner' s Court Tel: 020 7210 4850 Paderbor House Howell Croft North Bolton BLI 1QY 24 January 2017 Dzc N UJUL Thank you for your letter of 11 November 2016, following the inquest into the death of Ms Karen Ann Thorne. [ was to hear of her death and wish to extend my condolences to her family. Some of the matters you raise are for the Trust: For the concerns you raise about the shortage of radiologists , Department of Health officials have contacted Health Education England about its plans to recruit more trainees into radiology: I understand Health Education England is working in partnership with NHS England and a range of professional bodies to develop a shared vision and strategy for the diagnostics workforce. Clinical Radiology is a priority area: Clinical radiology includes the sub-specialty ofneuroradiology, and has been one of the five specialty reviews undertaken by Health Education England in 2016. Health Education England is committed to recruiting more trainees into diagnostics, including radiologists, and the number of commissioned trainees, in clinical radiology, has increased from 1,053 in 2013/14 to 1,144 in 2016/17. This includes an increase of 32 in training posts for 2016. However, increases this year in training numbers will not have an impact on available consultant workforce supply until 2023 at the earliest HEE is working with service providers and commissioners on alternative workforce models for delivery of diagnostic services This includes enabling radiographers and sonographers to develop advanced practitioner skills and career structures to undertake reporting thereby freeing radiologist time for more specialised work. that this information is useful. Thank you for bringing the circumstances of Thore s death to our attention. F6x YlnL PHILIP DUNNE sOITy large hope - Ms XaA

Report sections

Circumstances of the death

Karen Ann Thorne (hereinafter referred to as Deceased") died at Salford Royal Hospital, Eccles Old Road, Salford on the 13th June 2016. In 2005 the Deceased was diagnosed with Multiple Sclerosis and she had two relapses in 2010, which fulfilled the clinical criteria for rapidly evolving severe Multiple Sclerosis, and in December 2010 she attended Salford Royal delay "the

NHS Foundation Trust to discuss treatment options for her Multiple Sclerosis with the Neurology Consultant:
3. In April 2011, the treatment for rapidly evolving severe Multiple Sclerosis commenced with Natalizumab, which is drug given 28 days by infusion. The Deceased was advised that the drug carried small risk of a serious condition called Progressive Multifocal Leukoencephalopathy (hereinafter referred to as PML), which is a potentially life-threatening progressive viral disease that affects the brain, and the Deceased was monitored for the potential effects of PML annual Magnetic Resinance Scans (hereinafter referred to as MR Scans) of the brain with an annual Neurology clinic review. The MR Scans and the annual clinic reviews continued until May 2015 when the annual Scan was changed to a four monthly MR Scan following a re-assessment of the risk of PML, MR Scan was conducted on the 20t May 2015 and the Scan showed subtle changes consistent with PML but the subtle changes were not identified by the radiology report at the time The radiology report was not received for period of 50 days following the Scan on the 20t 2015 and during that time the Natalizumab infusions continued every 28
5. The next MR Scan was conducted on October 2015, which showed clear evidence of PML on the Scan but the report of the Scan did not identify

Copies sent to

2. The Chief Executive, Salford Royal NHS Foundation Trust; Stott Lane, Salford M6 8HD

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Report details

Reference: 2016-0408
Date of report: 11 November 2016
Coroner: Alan Walsh
Coroner area: Manchester (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: 6 Jan 2017 (estimated).

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.