Source · Prevention of Future Deaths

Leslie Carswell

Ref: 2016-0147 Date: 19 Apr 2016 Coroner: Louise Hunt Area: Birmingham and Solihull Responses identified: 1 / 2 View PDF

Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.

Date 19 Apr 2016
56-day deadline 15 Jun 2016
Responses identified 1 of 2
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.
View full coroner's concerns
(1) There were technical difficulties transmitting the CT scans taken at 00.50 to the Queen Elizabeth Hospital in Birmingham for review which is the protocol for the west midlands. This caused a delay in deciding a treatment plan_ heard evidence at the inquest that these concerns are ongoing and no resolution has been found: There is a concern that patients with urgent conditions could have lifesaving treatment delayed due to technical difficulties between the two trusts: and

Responses

1 respondent
Sandwell and West Birmingham Hospitals NHS / Health Body
13 Jun 2016 PDF
Action Taken

The Image Exchange Portal (IEP) Standard Operating Procedure was updated to clarify how images are transmitted, including contingencies for out of hours and documentation requirements. All radiographers are being trained in IEP and Image Link and a weekly data report from the CRIS system has been set up to monitor image transfers performed out of hours. (AI summary)

View full response
Dear Mrs Hunt Re: Report to Prevent Future Deaths Leslie_William Carswell am in receipt of your Report to Prevent Future Deaths in respect of Leslie William Carswell dated 20 April 2016,and in line with your requirements am responding within the 56 days allowed. As a Trust we have taken action to address the matter of concern you have highlighted in your letter, namely technical difficulties transmitting CT scans to the Queen Elizabeth Hospital as per the protocol for the West Midlands. have outlined below the actions that we have already initiated within the Trust: Procedure the Image Exchange Portal (IEP) Standard Operating Procedure was updated to clarify how images are transmitted, including contingencies for out of hours and / or if there is a technical fault: The updated procedure includes changes to documentation requirements for audit trail purposes This updated documentation procedure went live on 3 June 2016. System based audit trails are being looked into:
2. System configuration all three SWBH CT scanners can send images directly to UHB, One of the CT scanners at Sandwell Hospital can send to Birmingham Children's Hospital: Work to ensure all SWBH CT scanners are configured to send images to Heartlands and Birmingham Children's Hospital is in progress. Configuration to the Children's Hospital is scheduled for completion by mid-June A request for configuration work was submitted to IT colleagues at Heartlands in May 2016 and once approved it will take approximately two weeks to allow for firewall configuration and testing: These configurations will be a fixed point in our Managed Equipment Service specification. University of Birminghamn Teaching Hospital City JQuI, 1 015A9L49"

3. Training all radiographers (seventy members of staff who work various shift patterns) are trained in IEP and Image Link, with documented process for competency sign-off: Training commenced in June 2016 with a planned completion by the end of September 2016_ Audit monitoring weekly data report from the CRIS system has been set up to monitor image transfers performed out of hours, which is reviewed by the Group'$ management team: A second data report from the IEP system gives an independent result for cross-checking against the CRIS system report; These monitoring reports will identify the member f staff who transferred the images, the destination, the time, the modality type and summary of the patient details_ hope that have offered assurance that we have taken the points you raised seriously and have implemented actions to prevent re-occurrence_ However; if you have any further questions, please do not hesitate to contact Assistant Director of Governance on

Report sections

Investigation and inquest
On 10/12/2015 commenced an investigation into the death of Leslie William Carswell: The investigation concluded at the end of the inquest 19th April 2016. The conclusion of the inquest was that the deceased died from a brain bleed following a fall: There was a delay in reviewing the CT scan and administering beriplex more quickly which contributed to his death_
Circumstances of the death
The deceased was admitted to D7 at City Hospital on 18/11/15 following a transcatheter aortic valve implementation at New Cross Hospital: He was transferred to ward D47 on 22/11/15 for rehabilitation. He was assessed to be at high risk of falls. He was seen regularly by physiotherapists and assessed to be improving: He had capacity was informed to use his call bell when mobilising: At 19.25 on 29/11/15 the deceased was found face down on the floor having been to use the toilet: He was taken to Sandwell hospital emergency department; as per protocol, where a CT scan at 00.50 confirmed bilateral sub-acute on chronic subdural haematoma: A decision was made at 02.30 to give Beriplex to reverse the effects of warfarin however the deceased suffered a further serious bleed at 05.05 before this could be given; He died on the intensive care unit at 12.30on 30/11/15
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you Sandwell and West Birmingham Hospitals NHS trust have the power to take such action:

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Report details

Reference
2016-0147
Date of report
19 April 2016
Coroner
Louise Hunt
Coroner area
Birmingham and Solihull

Responses identified

Responses identified 1 of 2
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Jun 2016.

Sent to

Sandwell and West Birmingham NHS Trust
University Hospital Birmingham NHS Foundation Trust

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