Dear Mrs Mason Ref: Michael John Halfpenny University Hospitals of Leicester ~ws ~rus~ L~ice~ti~r ~y~l Ir►firrr'ary Chief Executive's Corridor Level 3, Balmoral Building Infirmary Square Leicester LE1 5WW Tel: 0116 258 8940 write with respect to the Regulation 28 letter sent by your Assistant Coroner, Mrs Brown, on 1St June 2017 and the concerns detailed therein relating to the University Hospitals of Leicester NHS Trust, which I accept. can confirm that we have taken immediate actions to remedy the safety matters identified and I will now detail these actions:- We have reviewed the process for rejecting imaging within the Trust. The guideline 'Process for the Rejection of Imaging Referrals' is being strengthened and updated and will now include an explicit requirement that rejected referrals need to have a clear statement of why the rejection has been made and a comment must be put on CRIS (the Radiology IT system) that a rejection letter has been sent to the referrer. This is being. led by our Service Manager for Imaging and it is anticipated that this guideline will be available by the end of July
2017.
2. We have implemented a new system for redirecting any imaging referrals that inadvertently get sent to the incorrect team. The Imaging Team, led by the Clinical Director for Imaging, has provided clear instructions to their administration and clerical staff to forward screening requests to the relevant service. A rejection letter will be sent to the referrer detailing the action that has been taken and any further actions required by them. Cont'd ..... University Hospitals of Leicester NHS Trust includes Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary. Website: www.leicestershospitals.nhs.uk Chairman: Mr Karamjit Singh CBE Chief Executive: Mr John Adler

3. With respect to the UHL Screening Committee, this group was established in January 2017 to provide oversight and governance to the increasing number of national screening programmes now in place, This committee was therefore not in place at the point that the request from the GP regarding Mr Halfpenny was made to the Trust. A key function of this Committee is to review the process of referrals, the validity of rejected cases (i.e. those that fall outside the scope of the screening programme) and of course, any incidents reported relating to screening programmes. This committee will augment the rigorous quality assurance element already required for screening programmes which is monitored by the Regional Screening Group. In addition to the above our Head of GP Services has sent out a new communication to GPs in our monthly GP newsletter to explicitly inform them of how to refer in to the Screening Programrne;~~:ay~.s~:,_; The Vascular Service is also planning to attend GP Protected Learning Time sessions to raise awareness. This will be overseen by our AAA Screening Programme Manager, and it is anticipated that this will be a rolling programme which will have commenced by the end of July 2017. Furthermore, local GPs use a system called PRISM which is a desktop application integrated into their electronic records that provide referral guidance. Our Associate Medical Director, working in collaboration with Primary Care colleagues, will arrange for the referral pathways for AAA patients to be added onto this system so that this information can be easily accessed at the point of patient care. It is anticipated that this will also have occurred by the end of August 2017. trust this response assures you that we have taken immediate and extensive actions and that we are working with internal colleagues and external partners to safeguard future users of the service.

Dear Mrs Mason Re: Michael John HALFPENNY Please find enclosed the signed final report regarding the Serious Incident investigation into this case. I can confirm that we have contacted the family the share the report. UHL have already shared their findings in relation to incident 2. The final report will also be shared with UHL to add timescales to their recommendations. Please accept my apologies for the delay, if you require any further information please let us know.

Dear Mrs Brown, Re: Michael J Halfpenny I am writing to you to submit further evidence to you on Mr Halfpenny's inquest. The matter has been fully discussed with all practitioners in the practice however, it was my colleague who saw Mr Halfpenny and requested the ultrasound. He has reflected on his involvement in Mr Halfpenny's care and has himself produced a significant event analysis. He has also written to the Radiology Department. I enclose his SEA, rejection letter from Radiology and his letter to Dr Rodgers, Radiologist who rejected the referral. I also wish to advise that I have discussed the matter with my colleagues at the CCG and this incident has been accelerated to ~~a serious incident" and will invoke a formal multi- agency review. Yours sincerely

Encs: SEA; rejection letter; Letter to Radiology

111 STATION ROAD,GLENFIELD,LEICESTER,LE3SGS Telephone 01162333600 Fax(Medical)01162333602

Significant Event Audit Record Date ofAudit
19.06.2017 JWT Reporter Initials ofPatient MH Patient Code Date ofIncident:09.12.2016 Incident Description: MH was a 77 year old man who presented to myself on 23.03.2016 with a productive cough,SOB and some wheeze in the evenings. I found,on examining him, he had some crepitations in the right side of his chest and duly prescribed him Amoxicillin(5 day course)for a chest infection. As he was leaving the room, MH mentioned to me that both brothers had aortic aneurysms diagnosed and had been treated for these. I decided that instead of booking him another appointment, to save time, I would refer him for an USS to check on this aortic aneurysm and I sent this to Glenfield Hospital, USS Department on 23.03.2016. In my clinical history, I explained that both his brothers had aortic aneurysms at the same age as the patient was then and that both had repair operations although, at this point he had no symptoms, I explained that given his history he needed screening for aortic aneurysm. 3 weeks later, on 14`" April, the request was rejected by , Consultant Radiologist at Glenfield Hospital. However,we did not receive the rejection unti125`h April. In all approximately 1 month from my original referral before we knew it had been rejected. At which point, I remember arranging a telephone appointment with MH for 29.04.2017 to discuss this. For some reason MH was not available and I commented on the record that I left a message on the answerphone. Unfortunately,for a reason I cannot explain,I did not further up on this at this point in time and it was then many months later when he presented to one ofmy pairtners, NC on 9.12.2016 with abdominal pain. MH was clearly unwell,clammy and appeared to be in severe pain. MH was in a dreadful state so my colleague arranged a 999 ambulance and he was duly taken to the LRI. The ambulance crew were working on a diagnosis of renal colic and administered Morphine. The casualty department was full and the patient then spent 1 '/2 hrs in the car park awaiting admission into the LRI. Subsequent events followed on from this and the patient ultimately passed away with a ruptured aortic aneurysm. A Coroner's inquest was held and at the time, it was my partner,NC who was asked to produce a report which he duly did but which focused on his involvement around the referral ofthe patient. He did not look further back to make any connection from the patient's previous history, up to the point before the day of the inquest when he reviewed the records more thoroughly and at which point he noticed the patient had presented to me with a chest infection but that having mentioned the patient's family history of aortic aneurysm, he had seen that I had referred him for an USS via Anglia Ice and that this had subsequently been declined by the hospital as"Screening not offered" Discussion Points(issues raised): Men in the UK have an USS for AAA in the year that they turn 65. I think the screening programme started after this patient was65 however,through my colleagues research, we became aware that patients who have a strong family history of aortic aneurysm can contact the screening department by ringing them directly or be referred directly for screening via their GP. In retrospect, when I saw this patient back in March,I recall seeing him very briefly at the door for the issue around his aneurysm and duly sent offthe referral. It is true that I wasn't aware that he should have gone via the screening service and that had he been seen in the normal screening manner then his aneurysm may have been picked up and ri~eatment received, which could have saved his life. Having received the rejection form, I arranged to speak to the patient about this but this conversation never happened and as a result was a failed telephone contact. I do not know why I did not pursue the patient beyond this and I can't explain this even now. It is my normal practice to act upon any rejection letters and failure to do so is very unusual for me. Had the patient been refen~ed via to the AAA screening service having received a perfectly clear indication ofwhy I felt he warranted the USS,then the USS would have taken place as I had originally hoped. I do feel could have highlighted his reasons for rejection and at the same time sign-posted him onto the appropriate AAA screening service or at least made it very clear to me in his rejection that this patient warranted referral onto the AAA screening service in a more clear way. In this patient's case the true significant event was the delay in admitting him into casualty which was unfortunate and was beyond the control ofus as GPs. A poll of the clinicians in the practice was also a quick way of identifying the lack of knowledge amongst my fellow clinicians ofthe availability of AAA screening and the method by which patients should be referred to this service.

Agreed Action Points: NC originally brought up this case for discussion in our practice meeting. Obviously following which,I was then able to investigate my involvement in the case. I have reflected on how aortic aneurysm should be investigated and have written with my own concerns aboutthe Radiology Departments dealing ofmy referral in the hope they will reflect upon this and reach their own lessons on this tragic case. I have discussed the case with my partners and have provided this SEA to be sent with my colleagues report to the Coroner. I will ensure a copy ofthis and my letter to . I will alter the way I deal with failed telephone appointments to include sending the patient an SMS message which will show what advice I have given the patient in terms offollowing up on the missed call which should make the process much more robust. We will produce some posters to put up in our waiting rooms to encourage any patients with a family history ofaortic aneurysm to self-refer for screening and we have also mentioned this to our PPG who produce a regular newsletter for inclusion. When sending a copy ofmy SEA to the Coroner,I will also include the photocopied rejection from the Radiology department. I will be discussing this SEA with my appraiser at my next appraisal. Having been informed ofmy involvement in this tragic event,I have felt compelled to arrange a meeting with Mrs Halfpenny to express my regret and explain my involvementin his care process. Responsible Person: All doctors to be aware ofself- referrals so they can sign-post appropriate risk patients. Our Operations Officer and Patient Services Manager to arrange for an appropriate poster(possibly to obtain one from the AAA Screening Dept) and liaise with ourPPG so they are able to include an item in their newsletter

THE GLENFIELI)SURGERY ,
-l 22 Jun 2017

Dr P Rogers Consultant Radiologist Department of Radiology Glenfield Hospital Groby Road Leicester LE39QP Re Mr Michael Halfpenny D.O.B.27Sep 1939

Dear Dr Rogers, am writing to you concerning a patient at the surgery, Mr Michael Halfpenny. Back in March, I saw him regarding a chest infection and as he was leaving my room he mentioned to me he had a strong family history of aortic aneurysms. In fact his brothers had both had aortic aneurysm repairs at the same age. He was asymptomatic but I felt he needed screening. referred him to the ultrasound department on 23rd March 2016. It was noted that the request was received by on 23~d March 2016 but it was passed for a comment and was rejected by yourself on 14th April 2016. However, we did not receive the letter of rejection until 25t"April 2016. Mr Halfpenny was rejected on the basis that `no screening was offered'. Mr Halfpenny, at the age of 76, had missed the National Screening Programme. The patient in question went on to develop abdominal pain and subsequently died of a ruptured aortic aneurysm on the 24th January 2017. His death has been a matter for the Coroner and one of my partners attended an inquest where several issues were raised. One issue was that the practice had not been aware of the screening structure for aortic aneurysm locally and that we had not received any leaflets or posters from the screening department in order to communicate the screening to patients. As a result, we have taken the liberty of designing our own posters to display in the building.

111 STATION ROAD,GLENFIELD,LEICESTER,LE38GS Telephone 01162333600 Fax(Medical)0116 2333602

When the letter of rejection was received, unfortunately no action was taken. I am unable to explain why this happened because I am normally attentive to any rejections from the department, but obviously we do deal with many reports and results and this one appears to have slipped through. As a result of this occurrence, I took a straw poll of my partners and found that of the 5 doctors within our immediate practice, there was very little awareness of any confirmed route of referral for aortic aneurysm screening. I know this is only a small number of clinicians however, I think it does highlight a potential problem within the general practice community. As a result of this tragic incident, I have had to reflect on my personal involvement in this case but it does appear from our discussions on this that there are issues that we feel the Radiology department need to be able to reflect upon. The patient saw me for an entire different reason and this was an addendum to the consultation. Rather than deferring this discussion to another point, I thought I would be helpful in sending in a requestfor an ultrasound scan. had enclosed pretty clear clinical reasoning behind the reason for the screening and I feel that simply to have this request rejected was particularly unhelpful given the serious, underlying clinical implication. As GPs we are required to deal with many health matters. We are not specialist radiology trained clinicians and we rely upon our secondary care clinicians with specialist knowledge in radiological investigative areas. Given a particular clinical need, we would expect some guidance as to the appropriateness or inappropriateness of a referral but with some sign- posting as to where the referral should be directed if not to that department and also of any further tests that are now available that we could avail ourselves of. At the heart of the issue, it is a patient and the patient had a clinical need. All of us are surely working towards this and in the spirit of co-operation, I feel you should have given some clarification as to where he should have then been sent, or it does not seem unreasonable that the request could have been passed directly through to the AAA screening department within Glenfield Hospital. Some form of sign-posting would have made his screening omission less likely and indeed had the original referral been passed through to the screening department, then obviously he would have received the necessary screening and this event may well not have taken place. Whilst I accept my responsibility within this, I do feel that we cannot know everything about everything and in an ideal world, yes, that would be possible however, reality is that there are certain areas where we might well have ideas of the possible routes of referral but to some extent rely upon our secondary care colleagues to point us in the new direction if that is deemed necessary.

Obviously, this tragic case has caused all of us to read up about the screening and ask searching questions as a result of which, I have personally completed an SEA. My partner, , who is Chair of the Leicester Medical Committee has included an article in the LMCs newsletter to disseminate learning to the entire GP community. He has also written a formal report for the Coroner detailing his involvement and including a copy of my letter to yourselves as well as my SEA report. think that an issue of this magnitude should cause all of us to reflect on how we could have done better by the patient and I would be grateful fi you could reflect upon these comments with your colleagues in the department. This situation should not have occurred and I feel that we can, with co-operative working, prevent this happening again in the future. Many thanks. Yours sincerely

Jeanessa27 Apr 201611:15
-.._,~. fE~.~ INITIAL ~q ~ I THo~ itals of Leicester ~jT~~~ ~FfQW TC? NHS Trust Radiology C7eparkment University Hospitals of Leicester ~`~~.~ F~AT1~N°~ NOt~I~/~L Telephone 011 2588765 Option 4 t

Glen~eld Surgery 111 Station Road Glenfieid Leicester Date; 22 Aprii 2016 LE38GS

Dear

We have received a referral ~n the 14/0 /16 tc~ make an appointment for the following patient. Patienx: Mr Michae{ J Halfpenny ~~t~ of birth: ~7109i1939

Examination: US Abdominal aorta Unfortunately, we are unable to proceed with this request at this time anti must return it to you far the following reason: { ~° the test Insufficient clinical ~ Yt~`~t~Kru A recentlprevious report answers the clinical question an the request () () Patient did not make contact Clarification is required as to tlis required tt~a timescale for the test () Signature illegible -unable to indentify referrer And/ other reasons for request rejec#ion: Any further comments about rejection: Please r~tum a complete referral farm via your normal route. We appreciate your support with this request and would like tc~ offer our apologies far any inconvenience caused. Yours sincerely, On behalf of Radiology C~eparkment. Trust Headquarters, Levet 3, Balmoral 8uii~iin~, L~iceste~ Ftayal Infingary, halrman Mr Kat~amiitsin9l~ Chin{ Exacutive Mr John Adlar ~-18463058 Iltllllllll1111~~llllillll~lllll~l~illlili~lllill~~~11141111 Mr Michael Halfpenny, printed 22 Jun 2017 14:55(page 1 of 1)

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~~

13t"June 2016 STRICTLY PRIVATE &CONFIDENTIAL TO BE OPENED BY ADDRESSEE ONLY Mrs L C Brown Assistant Coroner Leicester City and South Leicestershire The Town Hall Town Hall Square Leicester LE1 9BG Dear Mrs Brown, Re: Michael 7 Halfpenny I am responding further to your request for a response to your report of Regulation 28. I can confirm that after attending the inquest, I wrote up the case as a significant event and the practice has taken a number of actions to try and prevent such a circumstance in future. Our Managers have been in touch with the Aortic Screening Department and have confirmed that men over 65 who have missed a National Screening Programme can self-refer and that patients under the age of b5 who have a family history of aortic aneurysms can be referred by the practice. The screening department does not produce any appropriate communication materials with patients and the practice has taken the liberty of designing its own posters for display in the building. We have also had a discussion with our Patient Participation Group v~~h9c~ will be incl~!ding ~n ~;rticle in tl~~ r~axt edition of the newsletter and we are displaying the information on our television screens within the waiting areas. In order to disseminate learning to the wider GP community, I have taken the liberty of including a significant event analysis to our locality group which includes a number of practices that work within the South Leicestershire area. THE GLENFIELD SURGERY

111STATION ROAD,GLENFIELD,LEICESTER,LE38GS Telephone01162333600 Fax(Medical)01162333602

As Chair of the LMC, I am also intending to include an article in the LMC (Local Medical Committee) newsletter to disseminate learning to the entire GP community within Leicestershire. For your information, I enclose a copy of our significant audit report, the posters we are intending to display which will be A3 in size. Please let me know if there are any further queries.