Source · Prevention of Future Deaths

William Harnell

Ref: 2015-0384 Date: 22 Sep 2015 Coroner: Andrew Cox Area: Plymouth, Torbay and South Devon Responses identified: 3 / 3 View PDF

Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.

Date 22 Sep 2015

56-day deadline 17 Nov 2015

Responses identified 3 of 3

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Significant national delays in X-ray reporting due to a shortage of qualified radiologists pose a risk to patient care across the UK.

View full coroner's concerns

In the circumstances it is my statutory to report to you; , (1) Theard evidence during the course of the Inquest that delays in the reporting of X-rays are not peculiar to Plymouth Hospitals NHS Trust but are a National problem: was further told that this is as a consequence of a lack of qualified Radiologists to complete the reports

Responses

3 respondents

Department of Health Central Government

22 Sep 2015 PDF

Noted

The Department of Health acknowledges the concerns regarding delays in X-ray reporting and highlights actions being taken by Health Education England to increase the number of radiologists. (AI summary)

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From Ben Gummer MP Parliamentary Under Secretary of Stale for Care Quality Department Richmond House of Health 79 Whitehall London POCS 960072 SWIA 2NS Tel 020 7210 4850 Mr A. Cox Assistant Coroner Derriford Park 2 0 Oct 2015 Derriford Business Park Plymouth PL6 5QZ Le_ M 6 Thank you for - letter of 22nd September 2015, following the inquest into the death of William Harell: I was extremely SOrTY to hear of Mr Harnell's death and wish to extend my condolences to his family: This case highlights delays in the reporting of X-rays at Plymouth Hospitals NHS Trust; an issue that you were advised was a national problem and a direct consequence ofa lack of qualified radiologists nationally. The timely reporting of X-rays is an important issue for patient safety: The Royal College of Radiologists (RCR) recognise this and advise that most X-rays and scans should receive a formal interpretation (report) within two In February 2015,the RCR carried out a survey' of NHS Trusts in England to understand the full extent of reporting delays in radiology departments and how patients are waiting for results of their X-rays and scans. Key findings showed that whilst Radiology Departments were under pressure to minimise the number of unreported studies or lengthy waits for results, they faced challenges such as shortages of consultant radiologists, other resourcing issues and ever increasing demand. One of the recommendations in this report; (directed at Health Education England (HEE) and NHS England) was that more radiologists are recruited and trained. bttps Ilwww IcL ac uklsites/default/fileslpublication/Unreported_studies_Feb2OLS_pdf your days. long X-ray -

In addition, the report by the Independent Cancer Taskforce, Achieving World-Class Cancer Outcomes: A Strategy for England 2015-2020' recognises there is a shortage of radiologists across the country and makes the following recommendation on this issue: Recommendation 84: Health Education England should support improvements in the earlier diagnosis of cancer by working with the Royal College of Radiologists (RCR) and diagnostic experts in NHS England to review, on an annual basis, the number of radiology, diagnostic radiographers and nurse endoscopy training positions required to meet projected needs, and act urgently to address these needs. The Department of Health 's (DH) ALBs (including HEE) are considering the recommendations in this cancer strategy, and a response is expected in the autumn. HEE was established as the body to help improve the quality of care delivered to patients by ensuring that our future workforce is available in the right numbers with the right skills, values and competencies to meet their needs today and tomorTow. However; it is not responsible for setting curricular or the standards of training which is a duty for the regulatory bodies. officials have liaised with HEE concerning the lack of radiologists nationally: can advise that HEE will work with partners, including the RCR, to ensure that the NHS has available the right number of trained staff to deliver the current and future demand for diagnostic tests. In particular; HEE will work with Public Health England and NHS England to ensure the availability, for example, of sufficient supply of qualified radiologists to ensure that X-ray results are reported in a timely manner; while account of the wider diagnostic service To support this mandate, HEE is supporting a number of actions a8 part of its diagnostics workforce programme. A diagnostics workforce steering group, to be chaired by Professor Liz Hughes, Director of Education and Quality for London and South East; is set up to provide overarching governance_ In June 2014, the Centre for Workforce Intelligence (CfWI) was commissioned by DH and HEE to evidence on possible shortage occupations within the healthcare sector in England. A review of the Shortage Occupation List (SOL) was completed by the Migration Advisory Committee (MAC) and in April 2015, radiologists were added to SOL. http: Www_cancerresearchukorg sites/default/fileslachieving_world- class cancer_outcomes strategy for_england_20L5-2020pdf My key - taking being gather =

The number of posts advertised in any specific year is dependent on the number of trainees successfully completing their training and thereby releasing their National Training Numbers (NTN) and post for a new trainee to fill. Reductions in recruitment numbers in a specific year in no way indicate, on their OWn, a reduction in the volume of training commissioned. Over the last two years HEE have increased the number of training places available in radiology and in 2015,212 training posts were advertised across England with a 100 per cent fill rate. Included in this number were 16 new posts established as part of HEE's expansion in the specialty. At the last validated stocktake there were 952 clinical radiology trainees in England with a further 61 trainees on a break training due to maternity leave or *Out of Programme' learning or research experience. With a 5 year programme 952 would indicate an average output intake of 190, delays and extensions to training will lower this average number: This level of training and associated CCT output has enabled the consultant radiology workforce to grow by over 7Ofte a year between 2009 and 2013. (2278 to 2561- as per HSCIC) HEE' s proposed education and training commissions for 2015/16 are set out in their second national workforce plan for England and can be found at: www hee nhs ukywork-programmes workforce-planning I am grateful to youfor bringing the circumstances of Mr Harnell's death to my attention and Kope that you find this reply helpful . BEN GUMMER being from

Plymouth Hospital NHS Trust NHS / Health Body

22 Sep 2015 PDF

Action Taken

Plymouth Hospitals NHS Trust has reviewed processes so that all Emergency Department films and inpatient films between Sunday am and Friday 5pm are reported within 24 hours. They have also developed a fast code for radiologists and sent out a safety alert to physicians regarding MR protocols for potential hip injuries. (AI summary)

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Dear Mr Cox Re: William John Charles HARNELL In am responding in relation to communication received yourself on 22nd September 2015 relating to Mr Harnell: The communication related to concerns arising from recent inquest, which have been delivered to myself as the Medical Director, as part of Regulation 28, Schedule of Coroners and Justice Act 2009 In your letter; under sections 5 and 6, You raise 3 main concerns Delay in reporting of 5 days of the original pelvic radiograph:
2. A further of 2 to 3 days in obtaining a second pelvic radiograph: 3 Lack of perceived clarity by ward clinicians regarding the correct pathway to be used if x- rays are inconclusive in the context of potential hip injury_ will respond to these in order: Delays in Reporting There are considerable challenges in the delivery of prompt plain film reporting on a 24/7 basis, due to the increasing demands on our diagnostic service. We have, however; reviewed our processes in relation to the Emergency Department and inpatients, and can now confirm that all Emergency Department films and inpatients Sunday am and Friday Spm, are reported within 24 hours through a revised reporting system: AlI weekend radiographs between 8am and 1Opm will be reviewed by senior ED physician: A limited number of overnight weekend films (Saturday and Sunday 1Opm to 8am) will be reviewed on Monday morning: The maximum would be 60 hours for the Friday evening films_ We are pursuing a further improvement, which would identify sub sets of films in the context of trauma, which could be reported within 24 hours on Saturday and Sunday, and will institute this if feasible. Working in Partnership with (he Peninsula Medical School Chairman: Richard Crompton Chief Execulive: Ann Jamas from the delay from delay

2 We are currently endeavouring, with the support of our service improvement team, to perform all radiographs on the day on which are requested: We have seen considerable improvement in this area in recent months and are now seeking to sustain this_
3. In relation to MR protocol, we have developed a fast code for all Radiologists, which reminds clinicians that a normal radiograph does not exclude fracture and if there is failure of pain-free weightbearing and radiographs are normal, an MR is indicated. We have also sent out a safety alert to all Physicians, which emphasises this point. We hope this gives some reassurance that the issues identified through the inquest of Mr Harnell's are far loss likely to occur in future. With regards Yours Sincerel Dr Philip M Hughes MBBS MRCP FRCR Medical Director Working in Partnership with the Peninsula Medical School Chairman: Richard Crompton Chief Executive: Ann James they the key

william harnell

16 Feb 2016 PDF

Action Planned

Cornwall Council is asking for guidance to be produced and disseminated to staff regarding timely placements for people who need such placements. (AI summary)

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Dear Mr Cox William John Charles HARNELL Thank you for your letter f the 16 February 2016 to Trevor Doughty which has been passed to me for reply and also for your subsequent letter to me of the 5 May 2016. We received the copy of the Regulation 28 Report regarding Mr Harnell dated September 2015, in February this year; I can confirm that we have a dedicated Social Work Service working in Derriford Hospital and that staff have been reminded of the requirements to seek timely placements for people who need such placements. The staff working in the Hospital are dedicated and committed. These cases are often complex and need careful management: In response to the matters of concern cited in the Report: The team in the Hospital works closely with Health colleagues to determine the appropriate care; The team will work with Health colleagues to seek mental health input as required for any future cases: We acknowledge that on occasion there may be delays; however with our robust Senior Management oversight I do not expect such delays in future: I can confirm that this Local Authority is able to fund placements that fall within its remit: I note the comment about guidance to assist staff in such cases and am asking for this guidance to be produced and disseminated: I apologise for the further there has been in sending this reply. Please come back to me if you have any further queries

Report sections

Investigation and inquest

On 15/12/2014 commenced an investigation into the death of William John Charles Harnell then aged 67 . The investigation concluded at the end of the inquest on 15 September 2015. The conclusion of the inquest was that Mr Harnell died as the result of an accident He had suffered a fractured left neck of femur while attempting to mobilise from his wheelchair in the early hours of 22 October 2014. The cause of death was given as: Hospital Acquired Pneumonia; (b) Left Hip Fracture; Cerebral Vascular Event and left sided weakness_

Circumstances of the death

Mr Harnell was seen in the emergency department at 04.47 hours on 22 October 2014. An X-ray of his left hip was performed at 05.34 hours. This was interpreted as "not conclusive so it needs either repeat film with better analgesia/MRI to exclude fracture"_ Mr Harnell was admitted to the Medical Assessment Unit and from there on to Honeyford Ward where he came under the care of The was not formally reported until 27 October 2014 (5 after admission) The report noted that "the left hip is markedly rotated making interpretation difficult: There is no evidence of a fracture_ If there is ongoing clinical concern then a repeat is recommended" Mr Harnell was re-examined on 28 October when he was found to have a range of pain free movement On 29 October; however; the physiotherapy team noted that he was complaining of left hip and a repeat of the hip was requested: This did not take place until 2 November was not reported until 3 November when an impacted fracture of the left neck of femur was demonstrated. On 3 November it was decided that Mr Harnell should have non-operative management of his fractured hip with pain relief and mobilisation as tolerated: While he was fit for discharge from 4 or 5 November; Mr Harnell remained in Hospital until he developed Pneumonia and died on 15 December 2014. It was not clear from the evidence heard that the initial in reporting the first the subsequent delay in organising an the reporting of the second caused Mr Harnell's death 3 The Crescent; Plymouth, PLI 3AB Tel 01752 204 636 Fax 01752 313297 (a) being X-ray days X-ray good pain X-ray and delay X-ray and X-ray

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. heard evidence at Inquest fromg_ (that the Trust had made efforts to reduce the lengthy delays in X-ray reporting: was told that the situation had been improved but that there continued to be delays: was further told that this is a national problem (and not peculiar to Derriford) and consequently, have also written a Regulation 28 Report to the Department of Health: YouR RESPONSE You are under a to respond to this report within 56 days of the date of this report; namely by 17 November 2015. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed:

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Report details

Reference: 2015-0384
Date of report: 22 September 2015
Coroner: Andrew Cox
Coroner area: Plymouth, Torbay and South Devon

Responses identified

Responses identified 3 of 3

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Nov 2015.

Sent to

Department of Health and Social Care

Plymouth Hospitals NHS Trust

Social Services Truro Cornwall

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.