Derek Cole
PFD Report
All Responded
Ref: 2025-0162
All 1 response received
· Deadline: 21 May 2025
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Response Status
Responses
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56-Day Deadline
21 May 2025
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
1. It was accepted that the GP practice, when asked to perform tests by secondary services, should notify them of the results if they are abnormal. It was accepted that it should be confirmed in such circumstances that a follow up appointment is in place and considered whether any abnormal results should lead to a request for a more urgent review. It was also accepted that there was learning for the practice regarding this and that this could be discussed at a Significant Event meeting. However, despite Mr Cole dying in June 2024, at the time of inquest, 9 months later no such meeting or learning had taken place. While the evidence is that earlier specialist input would not have altered the outcome for Mr Cole, it is a concern that for other patients, a delay may impact upon their treatment options and prognosis.
2. The evidence was that any clinician could identify a concern for these meetings, or that usually it was for the Practice Manager to raise these when they were aware of a concern. The Practice were aware of the concerns as the inquest was listed and concerns raised by the family about delays were sent to the Practice to consider when providing their evidence for the inquest. However, this still did not trigger a review or any learning. It is therefore a concern that the Practice does not have a sufficient system in place to learn from such events which creates a risk that future deaths may occur in similar circumstances.
2. The evidence was that any clinician could identify a concern for these meetings, or that usually it was for the Practice Manager to raise these when they were aware of a concern. The Practice were aware of the concerns as the inquest was listed and concerns raised by the family about delays were sent to the Practice to consider when providing their evidence for the inquest. However, this still did not trigger a review or any learning. It is therefore a concern that the Practice does not have a sufficient system in place to learn from such events which creates a risk that future deaths may occur in similar circumstances.
Responses
The surgery has held a clinical meeting to address responsibility for communicating GP-generated results and has conducted a Significant Event Analysis (SEA). As a result, SEA and death reporting protocols have been amended and circulated to all clinicians, with training planned for June 2025 and a subsequent audit.
AI summary
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Dear Mrs Goward, am writing on behalf of the Attleborough Surgery in response to the matters of concern raised in your Prevention of Future Deaths Report dated 26 March 2025 relating to our patient, Mr Cole in order to provide you with information regarding the steps we have taken to ensure that there is no recurrence:
1. When secondary (hospital) services ask the practice to perform tests, the practice should notify them of the results if they are abnormal, confirm that a follow up appointment is in place and consider if the abnormal results should lead to a request for a more urgent review. The abnormal, GP-generated PSA results should have been notified to the hospital in order for them to confirm or expedite their proposed review appointment: They were not notified as should have been because the practice understood from hospital correspondence that a review appointment was taking place soon although no date had been confirmed: The hospital have access to the test results requested by the GP but they should have been notified by the practice as this would have prompted them to arrange and possibly expedite the review appointment Cont'd. they
Page 2_ The practice has had a clinical meeting to discuss responsibility for notification of GP-generated results to the hospital. Routinely when GPs request tests which are abnormal or relevant to their patient'$ treatment by secondary services, any abnormal results are communicated effectively and in a timely matter. When secondary services ask the practice to perform tests the practice should be provided with a hospital-generated ICE form. This ensures that the tests requested by the hospital are clearly set out and that are notified directly of the results. Where no hospital form is provided for a requested test, the GP actioning an investigation requested by the hospital becomes responsible for acting on the result: Informing the hospital immediately of the abnormal results and clinical update would have enabled them to review and expedite the next appointment and his treatment: The practice has discussed and circulated a new policy to ensure that all clinical staff are reminded of their responsibilities to communicate any abnormal test results to the hospital whether requested by the hospital or the GP. All results received are reviewed by a GP who makes a clinical decision about whether or not any further clinical update needs to be provided to the hospital with the abnormal result protocol specifically for investigations requested by the hospital has been developed introduced which requires: When the hospital requests investigation for a patient under their care, Reception should ensure that the patient has a hospital generated form when booking practice-based tests on behalf of the hospital. This will ensure that care remains appropriately with specialist hospital services, who will then receive results back directly, review and decide next steps for care planning: Where this form is not available, the practice should contact the hospital to request hospital-generated request form However, any tests should be proceeded with in the meantime with a practice-generated form if there is any urgency: The responsibility for managing a practice- generated result in this circumstance will rest with the practice: Results where the patient is under the care of the hospital should be prioritised by the clinician receiving them so that clinically significant results are dealt with appropriately: With the forwarding of straightforward results, the clinician will ask reception to inform the hospital: With any results needing the sharing of updating clinical information requesting further advice, this should be dealt with by the clinician directly: In Mr Cole's case, the hospital should not only have been given the results but also a clinical update Following these discussions, we identified that the issue of the hospital failing to provide blood forms for their own monitoring has been a problem for other patients at our practice: have therefore spoken to Executive Officer at the Norfolk & Waveney Local Medical Committee on behalf of the practice and made him aware of this issue: He confirmed the LMC raises such contract breaches with the Integrated Care Board on a regular basis and he advised me to raise the issue with the NNUH Medical Director Dr Bernard Brett, which have done. Cont'd_ thev and
Page 3_
2. Mr Cole's case should have resulted in an SEA at several points including: When it was clear that there was a delay in secondary care receiving the abnormal results. When it became clear that there was a resulting delay to important treatment for Mr Cole. When the practice was asked for a statement by the Coroner. The SEA took place on 16.04.25. As a result; the SEA protocol has been amended and circulated to all clinicians. There is clarification that it is the responsibility of the clinician involved in the patient's care to report to the Practice Manager and Practice PA, but any staff member who identifies a concern should also have a low threshold for reporting to them as well. Similarly, any staff member with a concern that a significant/critical event could have taken place should have a low threshold for discussing the case with a colleague: In addition, the SEA and reporting of deaths protocols has been amended to specifically include any delay in care and/or any near miss which did not cause harm but could do so if it happened again: Training for GPs and all staff is planned for 04.06.25 to cover the new protocols, which have already been circulated: The surgery plans an audit of all deaths over the next 3 months to measure how many are being referred appropriately for a SEA, according to the amended protocol: The audit will then be presented for discussion at a clinical meeting at the practice: wish to make clear how seriously | and the practice take the issues that you have raised and hope you are reassured by the steps the practice has undertaken and has planned to prevent future recurrence: Siincerellv
1. When secondary (hospital) services ask the practice to perform tests, the practice should notify them of the results if they are abnormal, confirm that a follow up appointment is in place and consider if the abnormal results should lead to a request for a more urgent review. The abnormal, GP-generated PSA results should have been notified to the hospital in order for them to confirm or expedite their proposed review appointment: They were not notified as should have been because the practice understood from hospital correspondence that a review appointment was taking place soon although no date had been confirmed: The hospital have access to the test results requested by the GP but they should have been notified by the practice as this would have prompted them to arrange and possibly expedite the review appointment Cont'd. they
Page 2_ The practice has had a clinical meeting to discuss responsibility for notification of GP-generated results to the hospital. Routinely when GPs request tests which are abnormal or relevant to their patient'$ treatment by secondary services, any abnormal results are communicated effectively and in a timely matter. When secondary services ask the practice to perform tests the practice should be provided with a hospital-generated ICE form. This ensures that the tests requested by the hospital are clearly set out and that are notified directly of the results. Where no hospital form is provided for a requested test, the GP actioning an investigation requested by the hospital becomes responsible for acting on the result: Informing the hospital immediately of the abnormal results and clinical update would have enabled them to review and expedite the next appointment and his treatment: The practice has discussed and circulated a new policy to ensure that all clinical staff are reminded of their responsibilities to communicate any abnormal test results to the hospital whether requested by the hospital or the GP. All results received are reviewed by a GP who makes a clinical decision about whether or not any further clinical update needs to be provided to the hospital with the abnormal result protocol specifically for investigations requested by the hospital has been developed introduced which requires: When the hospital requests investigation for a patient under their care, Reception should ensure that the patient has a hospital generated form when booking practice-based tests on behalf of the hospital. This will ensure that care remains appropriately with specialist hospital services, who will then receive results back directly, review and decide next steps for care planning: Where this form is not available, the practice should contact the hospital to request hospital-generated request form However, any tests should be proceeded with in the meantime with a practice-generated form if there is any urgency: The responsibility for managing a practice- generated result in this circumstance will rest with the practice: Results where the patient is under the care of the hospital should be prioritised by the clinician receiving them so that clinically significant results are dealt with appropriately: With the forwarding of straightforward results, the clinician will ask reception to inform the hospital: With any results needing the sharing of updating clinical information requesting further advice, this should be dealt with by the clinician directly: In Mr Cole's case, the hospital should not only have been given the results but also a clinical update Following these discussions, we identified that the issue of the hospital failing to provide blood forms for their own monitoring has been a problem for other patients at our practice: have therefore spoken to Executive Officer at the Norfolk & Waveney Local Medical Committee on behalf of the practice and made him aware of this issue: He confirmed the LMC raises such contract breaches with the Integrated Care Board on a regular basis and he advised me to raise the issue with the NNUH Medical Director Dr Bernard Brett, which have done. Cont'd_ thev and
Page 3_
2. Mr Cole's case should have resulted in an SEA at several points including: When it was clear that there was a delay in secondary care receiving the abnormal results. When it became clear that there was a resulting delay to important treatment for Mr Cole. When the practice was asked for a statement by the Coroner. The SEA took place on 16.04.25. As a result; the SEA protocol has been amended and circulated to all clinicians. There is clarification that it is the responsibility of the clinician involved in the patient's care to report to the Practice Manager and Practice PA, but any staff member who identifies a concern should also have a low threshold for reporting to them as well. Similarly, any staff member with a concern that a significant/critical event could have taken place should have a low threshold for discussing the case with a colleague: In addition, the SEA and reporting of deaths protocols has been amended to specifically include any delay in care and/or any near miss which did not cause harm but could do so if it happened again: Training for GPs and all staff is planned for 04.06.25 to cover the new protocols, which have already been circulated: The surgery plans an audit of all deaths over the next 3 months to measure how many are being referred appropriately for a SEA, according to the amended protocol: The audit will then be presented for discussion at a clinical meeting at the practice: wish to make clear how seriously | and the practice take the issues that you have raised and hope you are reassured by the steps the practice has undertaken and has planned to prevent future recurrence: Siincerellv
Report Sections
Investigation and Inquest
On 04 July 2024 I commenced an investigation into the death of Derek William COLE aged
81. The investigation concluded at the end of the inquest on 25 March 2025. The medical cause of death was: 1a) Metastatic Prostate Cancer and Emphysema 1b) 1c)
2) The conclusion of the inquest was: Natural causes
81. The investigation concluded at the end of the inquest on 25 March 2025. The medical cause of death was: 1a) Metastatic Prostate Cancer and Emphysema 1b) 1c)
2) The conclusion of the inquest was: Natural causes
Circumstances of the Death
Derek Cole was diagnosed with prostate cancer after he had raised PSA (prostate specific antigen) marker levels which rapidly increased over a short period of time. An initial bone scan in December 2023 showed no evidence of metastatic spread, but a further scan on 7 May 2024 showed extensive metastatic disease. He was admitted to hospital on 27 May 2024 and was found to have raised inflammatory markers and an acute kidney injury secondary to infection. He was treated and improved sufficiently that he was fit for discharge, pending a package of care being sourced. While awaiting this he had a suspected chest infection which was also treated and from which he recovered. He was discharged to Dereham Hospital on 15 June 2024 for rehabilitation. In the early hours of 16 June 2024, he was found unresponsive in bed and in line with previously expressed wishes, no resuscitation measures were undertaken. The findings on the evidence heard included that a GP appropriately referred Mr Cole to the hospital Urology team in November 2023 due to high PSA of 25.6 (I was advised anything over 10 in a gentleman of Mr Cole’s age is to be referred). He was seen by the Urology team in December 2023 and a bone scan showed no evidence of metastasis, which was reassuring, and they requested that the GP perform a further PSA test in 2 months, and this was done on 12 January 2024 and the result was slightly raised from the earlier test at
37. There was then a further PSA test in February which showed what a Urologist who gave evidence described as a significant raise to 156.3. His evidence was that this was an unusually high rise in a short period of time for a man in his 80s. This was therefore something which should have been flagged up immediately to the Urology team by the GP receiving the result, but it was not as they believed (but were unable to explain why) he had a follow up appointment shortly with urology and that they would see the result then. There was then another test in April, with a PSA which was said to be very high at 510. At this time a check was made by a GP that there was a follow up appointment in place, and this led to a further bone scan which was done 7 May 2024 and confirmed multiple metastases. Had the results from February 2024 been flagged to Urology, on the balance of probabilities, Mr Cole would have undergone further tests at the hospital to check the PSA raise was genuine, which it would have been, and treatment would have started in February or early March. This would have been the same treatment as was later started in May. The evidence in this case was that the extent and speed of the spread was very rare in a man of Mr Cole’s age, and this was due to it being an aggressive form of the cancer and that, on the balance of probabilities, earlier commencement of treatment would not have altered the outcome or changed the treatment options which were suitable.
37. There was then a further PSA test in February which showed what a Urologist who gave evidence described as a significant raise to 156.3. His evidence was that this was an unusually high rise in a short period of time for a man in his 80s. This was therefore something which should have been flagged up immediately to the Urology team by the GP receiving the result, but it was not as they believed (but were unable to explain why) he had a follow up appointment shortly with urology and that they would see the result then. There was then another test in April, with a PSA which was said to be very high at 510. At this time a check was made by a GP that there was a follow up appointment in place, and this led to a further bone scan which was done 7 May 2024 and confirmed multiple metastases. Had the results from February 2024 been flagged to Urology, on the balance of probabilities, Mr Cole would have undergone further tests at the hospital to check the PSA raise was genuine, which it would have been, and treatment would have started in February or early March. This would have been the same treatment as was later started in May. The evidence in this case was that the extent and speed of the spread was very rare in a man of Mr Cole’s age, and this was due to it being an aggressive form of the cancer and that, on the balance of probabilities, earlier commencement of treatment would not have altered the outcome or changed the treatment options which were suitable.
Copies Sent To
spouse. CQC HSSIB (Health Services Investigations Body) Healthwatch Norfolk
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.