A Briggs
Action Planned
The Trust will strengthen communication between secretarial teams at Stepping Hill and Buxton to ensure radiology reports are available at both sites simultaneously. They will develop a standard operating procedure for sending all radiology reports from Buxton to Stepping Hill, regardless of urgency. (AI summary)
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Dear Mr Pollard, Re: Antony Edmund BRIGGS (Deceased) Thank you for your letter; of 28 January 2016 , concerning the inquest of the above named patient As always am grateful to you for highlighting your concerns on the Regulation 28 'Report to prevent future deaths' and for providing me with an opportunity to respond Your concerns are as follows:
1) The system that operates at Buxton Is different from that at Stepping Hill and therefore doctors cannot look at the test results on screen at Stepping Hilland 2) The Urologists see patients at Stockport; Tameside, Macclesfield and Buxton. At all of these locations, the data can be input so as to be viewable at Stepping Hill, save and except for Buxton: This is correct for Radiological tests and is historical in that the two systems were developed entirely independently of each other by different NHS Trusts. Radiology at Buxton Is managed by Chesterfield Royal Hospital NHS Foundation Trust and images are uploaded io their Picture Archiving and Communication System (PACS), t0 which Stockport NHS Foundation Trust does not have access. However; visiting Stepping Hill consultants can view the images reports on the Chesterfield PACS system when visit Buxton: Paper copies of Radiology reports for images taken at Buxton are sent to the Stepping Hill consultant's secretary at Buxton and if these are noted as urgent; or if the secretary knows the consultant is not going to visit Buxton for few weeks, e.g. because of leave, then the Buxton secretary will send the report to the consultants secretary at Stepping Hill. All other tests carried out at Buxton hospital, such as biopsies, or samples of blood, sputum and urine are sent to Stepping Hill's laboratory and so the results of these tests are uploaded to the 'Advantis' system and are visible to staff at both hospitals: All letters typed at Buxton are typed onto the same Advantis system ad are therefore viewable at both hospitals_
3) When the Urologists view is not available on screen at Stepping Hill; it should apparently fall to the local GP's in Buxton to act on the information, but either cannot or do not; thus the patient falls into a Iacuna and no action is pursued_ This is always of importance but especially s0 with aggressive malignancy. Mr Briggs was referred to Urology at Buxton on 14 January 2015 and seen on 23 January; he was referred to Buxton X-ray for a Ultra sound scan (non-urgent') and for a flexible cystoscopy at Stepping Hill; The ultrasound scan was undertaken at Buxton on the 23 February: The report for the scan was also done on 23 February and typed up and sent to the secretary at Buxton on 23 February: The secretary sent it to Mr Brown for his review when he next attended Buxton, on 6 March Your Health: Our Priority: they and they very
Mr Brown saw the report and he dictated a letter stating that there was 'thickening of the bladder wall and that this may indicate a malignancy'; however the same appearance could also indicate high pressure chronic retention or chronic cystitis. Mr Brown therefore advised the G.P. that the patient was awaiting a flexible cystoscopy and that he would be in touch as soon as this was done; his assumption that the ultrasound report and the cystoscopy would be viewed in context with each other: Mr Briggs was then seen at Stepping Hill on 10 March 2015 by a Registrar and the flexible cystoscopy was undertaken; the appearance of the bladder seemed 'normal' to the Registrar ad he wrote a letter to Mr Briggs' G.P advising him of this and that he would 'send the ultrasound report when available' It was later noted, in the letter dictated by Mr Brown on 6 March, by the Buxton secretary that the flexible cystoscopy had been done on 10 March but not reported on; this letter was not typed into the Advantis system until 11 March; The courses of action taken by Mr Brown and the Registrar; in themselves, were perfectly reasonable; Mr Brown thinking that the cystoscopy would be undertaken with the Registrar having benefit of sight of his letter and the Registrar, having viewed what he felt to be a normal bladder; informing the G.P_ of this and that he would write to Mr Briggs with the results of the ultrasound scan, once known It is worthy of note at this point that Mr Briggs had an extremely rare form of cancer; an infiltrating adeno- carcinoma: One would normally expect to see, if a bladder tumour were present, papillary areas that were very obvious: The Registrar; at his level of experience, acted appropriately and he cannot be criticised for not detecting the adeno-carcinoma; indeed it is very possible that consultant under the same set of circumstances may not have detected it either: The ultrasound scan report was not marked 'urgent'_ as the index of suspicion regarding the appearance of the bladder was not high enough for the reporter given that, as mentioned previously, the same appearance could be the result of high pressure chronic retention or chronic cystitis_ This, in addition to the "time lag' in getting Mr: Brown's letter typed into the Advantis system and the fact that the Registrar was not aware of the report contributed to the delay in the diagnosis of Mr Briggs' adeno-carcinoma Although extremely rare, this case has clearly exposed a weakness in our communications between Buxton and Stepping Hill:
4) This man had an infiltrating adeno-carcinoma, which is very rare: This fact was not picked up as soon as it could have been and was not; therefore, acted upon_ have answered this point earlier in this response Action We will strengthen communications between the secretarial teams at Stepping Hill and Buxton to ensure that Radiology reports are made available to both sites at the same time One way of doing this will be to jointly develop and agreed a robust standard operating procedure to ensure that all reports for Radiology activity undertaken at Buxton on behalf of Stepping Hill, regardless of whether or not they are marked urgent; are sent over to the relevant consultant's secretary at Stepping Hill for the necessary review and action. hope that this response answers your concerns and provides you with the assurance that the Trust is committed to improving the quality of care we give to all our patients. Please do not hesitate to contact me if you have any further questions regarding this matter:
1) The system that operates at Buxton Is different from that at Stepping Hill and therefore doctors cannot look at the test results on screen at Stepping Hilland 2) The Urologists see patients at Stockport; Tameside, Macclesfield and Buxton. At all of these locations, the data can be input so as to be viewable at Stepping Hill, save and except for Buxton: This is correct for Radiological tests and is historical in that the two systems were developed entirely independently of each other by different NHS Trusts. Radiology at Buxton Is managed by Chesterfield Royal Hospital NHS Foundation Trust and images are uploaded io their Picture Archiving and Communication System (PACS), t0 which Stockport NHS Foundation Trust does not have access. However; visiting Stepping Hill consultants can view the images reports on the Chesterfield PACS system when visit Buxton: Paper copies of Radiology reports for images taken at Buxton are sent to the Stepping Hill consultant's secretary at Buxton and if these are noted as urgent; or if the secretary knows the consultant is not going to visit Buxton for few weeks, e.g. because of leave, then the Buxton secretary will send the report to the consultants secretary at Stepping Hill. All other tests carried out at Buxton hospital, such as biopsies, or samples of blood, sputum and urine are sent to Stepping Hill's laboratory and so the results of these tests are uploaded to the 'Advantis' system and are visible to staff at both hospitals: All letters typed at Buxton are typed onto the same Advantis system ad are therefore viewable at both hospitals_
3) When the Urologists view is not available on screen at Stepping Hill; it should apparently fall to the local GP's in Buxton to act on the information, but either cannot or do not; thus the patient falls into a Iacuna and no action is pursued_ This is always of importance but especially s0 with aggressive malignancy. Mr Briggs was referred to Urology at Buxton on 14 January 2015 and seen on 23 January; he was referred to Buxton X-ray for a Ultra sound scan (non-urgent') and for a flexible cystoscopy at Stepping Hill; The ultrasound scan was undertaken at Buxton on the 23 February: The report for the scan was also done on 23 February and typed up and sent to the secretary at Buxton on 23 February: The secretary sent it to Mr Brown for his review when he next attended Buxton, on 6 March Your Health: Our Priority: they and they very
Mr Brown saw the report and he dictated a letter stating that there was 'thickening of the bladder wall and that this may indicate a malignancy'; however the same appearance could also indicate high pressure chronic retention or chronic cystitis. Mr Brown therefore advised the G.P. that the patient was awaiting a flexible cystoscopy and that he would be in touch as soon as this was done; his assumption that the ultrasound report and the cystoscopy would be viewed in context with each other: Mr Briggs was then seen at Stepping Hill on 10 March 2015 by a Registrar and the flexible cystoscopy was undertaken; the appearance of the bladder seemed 'normal' to the Registrar ad he wrote a letter to Mr Briggs' G.P advising him of this and that he would 'send the ultrasound report when available' It was later noted, in the letter dictated by Mr Brown on 6 March, by the Buxton secretary that the flexible cystoscopy had been done on 10 March but not reported on; this letter was not typed into the Advantis system until 11 March; The courses of action taken by Mr Brown and the Registrar; in themselves, were perfectly reasonable; Mr Brown thinking that the cystoscopy would be undertaken with the Registrar having benefit of sight of his letter and the Registrar, having viewed what he felt to be a normal bladder; informing the G.P_ of this and that he would write to Mr Briggs with the results of the ultrasound scan, once known It is worthy of note at this point that Mr Briggs had an extremely rare form of cancer; an infiltrating adeno- carcinoma: One would normally expect to see, if a bladder tumour were present, papillary areas that were very obvious: The Registrar; at his level of experience, acted appropriately and he cannot be criticised for not detecting the adeno-carcinoma; indeed it is very possible that consultant under the same set of circumstances may not have detected it either: The ultrasound scan report was not marked 'urgent'_ as the index of suspicion regarding the appearance of the bladder was not high enough for the reporter given that, as mentioned previously, the same appearance could be the result of high pressure chronic retention or chronic cystitis_ This, in addition to the "time lag' in getting Mr: Brown's letter typed into the Advantis system and the fact that the Registrar was not aware of the report contributed to the delay in the diagnosis of Mr Briggs' adeno-carcinoma Although extremely rare, this case has clearly exposed a weakness in our communications between Buxton and Stepping Hill:
4) This man had an infiltrating adeno-carcinoma, which is very rare: This fact was not picked up as soon as it could have been and was not; therefore, acted upon_ have answered this point earlier in this response Action We will strengthen communications between the secretarial teams at Stepping Hill and Buxton to ensure that Radiology reports are made available to both sites at the same time One way of doing this will be to jointly develop and agreed a robust standard operating procedure to ensure that all reports for Radiology activity undertaken at Buxton on behalf of Stepping Hill, regardless of whether or not they are marked urgent; are sent over to the relevant consultant's secretary at Stepping Hill for the necessary review and action. hope that this response answers your concerns and provides you with the assurance that the Trust is committed to improving the quality of care we give to all our patients. Please do not hesitate to contact me if you have any further questions regarding this matter: