Source · Prevention of Future Deaths

Mary Hollands

Date: 21 Dec 2015 Coroner: Nicola Jones Area: North Wales (East and Central) Responses identified: 1 / 1 View PDF

The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries may be missed and patient safety netting is ineffective.

Date 21 Dec 2015

56-day deadline 15 Feb 2016

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The system for providing radiologist reports to the Emergency Department is unreliable, creating a risk that subtle injuries may be missed and patient safety netting is ineffective.

View full coroner's concerns

(1) The system currently in place for radiologist'$ reports passed to the Emergency Department is not sufficiently reliable or safe $o as to provide effective safety netting for patients_ (2) Under the current system the x ray will be put o the PACS system and any obvious injury will have the words "red dot" typed on the area of the injury. The Emergency Department doctor must all X-rays to check for an injury, whether Or not marked with "Tred dot". This is then followed with a radiologists report within 48 hours_ The report is put on the PACS system and a paper copy is despatched to the Emergency Department and attached to the notes The radiologist will in his report note any injuries which he has seen This provides a safety net where an Emergency Department doctor have missed a more subtle SO that a patient, whom has been discharged can be recalled for future advice andlor treatment _ (3) There is currently no coding system for radiologists to make those reports which identify injuries easily identifiable so that the Emergency Department can prioritise the reading of reports with a view to recalling patients whose injuries have gone undetected This is in the context of some 50000 patients passing through each Emergency Department each year; an average of one third of whom are X rayed Time is currently being wasted in an already department ploughing through reports which do not need to be considered as no injury is disclosed.

(4) Also the method of passing the paper information to the Emergency Department is flawed. There are regular occasions when paper report does not arrive, as happened in the case of Mrs Hollands, meaning that some patients are not recalled for necessary advice and treatment; as in the case of Mrs Hollands_ Once the paper report arrives in the Emergency Department the paper notes have to be located and the Paper report attached before it can be considered in context On occasion a radiologist will come down and discuss a report. There appears to be a lack of consistency (5) There needs to be a reliable system for the report of the radiologist to be delivered to the Emergency Department; prioritising patient'$ with injuries. An optimum system could be devised between senior Consultant Radiologists and Senior Consultant Emergency doctors This needs to be considered for use prior to digitalisation of Emergency Department notes and incorporated into the anticipated digitalised system Mrs being bony analyse injury may busy those busy the

Responses

1 respondent

Mary Hollands

29 Feb 2016 PDF

Action Planned

Betsi Cadwaladr University Health Board has established a task group to address diagnostic test result review and is developing a new procedure, currently in final consultation stages. They are also working on an interim solution for electronic communication of radiology results and will consider IT system integration. However, they dispute the feasibility of a coding system or direct radiologist communication for every report due to practicality. (AI summary)

View full response

Dear Mr Gittins

Re: Regulation 28: report to prevent future deaths

BCU Health Board is grateful to the Assistant Coroner for her report, and is taking the findings extremely seriously in order to prevent deaths or serious harm in the future.

The matters of concern relate to the process of review of radiographic images in the Emergency Department at the time the patient attended and the review procedure following the receipt of the formal report produced by the Radiology Department.

It is well recognised that even with the "red dot" process in place to help Emergency Department clinicians identify injuries there will be a number that are picked up subsequently by the radiology department during formal reporting. The Emergency Departments have safety net systems in place to review the radiology reports against the clinical outcomes to try to prevent failures to act.

During the summer of 2015 a task and finish group was established to look at the issues related to failure to act for all diagnostic test results and agree standards that clinical teams should work too. From this piece of work a procedure has been developed that is in its final stages of production and consultation. This work highlighted previous messages from the Medical Director reminding staff who refer for diagnostic tests of their professional responsibility to ensure results are reviewed and acted upon. In the case of diagnostic imaging the Ionising Radiation (Medical Exposure) Regulations 2000 places a duty on the referrer to ensure there is a documented outcome for each examination requested.

Matters of concern paragraph 3. The suggestion is for a coding system to be in place. However, as the radiologists do not have the full clinical picture of the care given to the patient following their imaging it would be difficult to develop such a system.

Matters of concern paragraph 4. In accordance with the Welsh Medical Imaging Sub- Committee standards for unexpected findings a radiologist would communicate directly by phone or in person if an emergency or life threatening condition was

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives' Office, Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk

**Page 2** GIG CYMRU NHS WALES Bwrdd lechyd Prifysgol Betsi Cadwaladr University Health Board

detected. This would not be practical for every examination reported due to the volume of reports performed.

There is currently no electronic system available to highlight results and confirm that they have been received by the referrer. However the Radiology and Emergency departments are working together to develop an interim solution to ensure the results are communicated and received by the referring department.

Matters of concern paragraph 5. The health board will consider what integration of the Radiology and Emergency Department IT systems can be undertaken to support the communication process.

Please see the enclosed action plan in support of the review. This action plan will be monitored by the Health Board's Quality and Safety Committee (which reports direct to the Board) and local committees on each site. We will provide you with detailed evidence of long term actions detailed within the action plan as soon as possible and with an update report before the end of May 2016.

Report sections

Investigation and inquest

On 29 July 2015 commenced an investigation into the death of Mrs Mary Myfanwy Hollands, aged 98. The investigation concluded at the end of the Inquest on 3 December 2015 The conclusion of the Inquest was that Mrs Hollands died from natural causes_ The medical cause of death was I(a) Ischaemic Heart disease Pneumonia: Old Age, Dementia_

Circumstances of the death

(1) Mrs Hollands was a 98 year old lady with dementia She sustained an unwitnessed fall at the nursing home where she lived and was transported to Ysbyty Gwynedd by ambulance_ She complained of pain in her left shoulder and left hip. Xrays where taken of the shoulder and Both of these were examined and the junior doctor who reviewed the X ray of the hip could not see bony injury: It was believed that Mrs Hollands was suffering from a UTI and she was given antibiotics Mrs Hollands was transferred to the medical team and was subsequently discharged_ (2) She then deteriorated over the next four weeks and washer less mobile than before the fall. She was admitted by ambulance to Ysbyty Glan Clwyd on 10 2015. As well as treating Mrs Hollands for dehydration and an infection an xray was taken of her left hip. This revealed a bony injury. Whilst this could not be dated it was confirmed that the result was the same as the xray taken weeks earlier. The bony injury had been missed on the previous occasion at Ysbyty Clwyd. Mrs Hollands was not strong enough for surgical intervention and she was discharged with advice that the hip injury be managed conservatively. Mrs Hollands continued to deteriorate and died on 27 July 2015 It is accepted that the hip injury was very difficult to identify. In these circumstances there is a safety netting system in place: A radiologist considers the X-ray and does a report within 48 hours which is sent to the Emergency Department: In Hollands' case the Consultant Radiologist reported that there was step in the cortex of the medial It neck raising_the_ possibility of an undisplaced fracture lf there are ongoing hip: any July four Glan Mrs symptoms, then a repeat film with a lateral is recommended. The paper copy of this report never arrived in the Emergency Department_ By the time the report was signed off Hollands had been discharged: The Emergency Department were not alerted to the possibility of the fracture_ Whilst the report was put on the PACS system there was no prompt for the Emergency Department staff to consider this_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe your organisations have the power to take such action_

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Date of report: 21 December 2015
Coroner: Nicola Jones
Coroner area: North Wales (East and Central)

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: 15 Feb 2016.

Sent to

BCUHB, Ysbyty Gwynedd

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk.

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