Dear Ms Mutch,

Re: Regulation 28 Report to Prevent Future Deaths – Graham Flindle 06/05/22

Thank you for your Regulation 28 Report dated 04/11/22 concerning the sad death of Graham Flindle on 06/05/22. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to begin by offering our sincere condolences to Mr. Flindle’s family for their loss.

Thank you for highlighting your concerns during Mr. Flindle’s Inquest which concluded on 17 October
2022. On behalf of NHS GM, I apologise that you have had to bring these matters of concern to our attention but it is also very important to ensure we make the necessary improvements to the quality and safety of future services.

Following the inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future deaths will occur unless action is taken. The inquest concluded that Graham’s death was as a consequence of the recognised complications of previous necessary surgery. The medical cause of death was 1a) Pneumonia; 1b) Right hemicolectomy; 1c) Cecal cancer; and 2) Chronic obstructive pulmonary disease.

I hope our response below demonstrates to you and Mr. Flindle’s family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system.

This letter addresses the issues that fall within the remit of NHS GM and how we can share the learning from this case.

Cancer Alliances are the primary vehicle for delivery of the NHS Long Term Plan ambitions for cancer and improvements in cancer performance, as they bring together partners across complex cancer pathways to deliver the best care and outcomes for patients. By leading systems and service delivery, they were central to the success in maintaining cancer services during the pandemic. Cancer Alliances have been in place since 2016 and there are now 21 Cancer Alliances, of which GM is one. They are responsible for leading the planning and delivery of cancer services and for leading work across their local system to: Diagnose cancer earlier and improve survival, speed up cancer pathways, improve patient experience and quality of life and reduce health inequalities in cancer services. Critical is the cancer alliances role in ensuring the whole cancer pathway from Primary care to Secondary care and beyond is continually reviewed to make improvements across all aspects of cancer pathways, supported by clinically lead pathway boards across all cancer specialities.

The inquest heard that FIT tests were very effective at identifying bowel cancers at an early stage. GPs and other community health care providers, the inquest heard, have a key role in promoting the use of them where there is rectal bleeding/unexplained weight loss and other symptoms that may be consistent with bowel cancer. Use of FIT tests allows far more effective identification of patients who need to be fast tracked onto the cancer pathway. An understanding of just how effective FIT tests are was not always widely understood and promotion of them amongst all community health professionals was, the inquest was told, crucial in reducing deaths from bowel cancer.

Over the last 12 months guidance of the use of FIT has changed and patients would now have FIT prior to onward referral to secondary care. A positive test would prompt the secondary care clinician to investigate the whole colon. The suspected cancer referral form is being altered to provide a reminder to referrers of the need to do FIT prior to referral.

The Cancer Alliance is running an ongoing education and awareness programme for primary care practitioners on the use of FIT in patients with possible symptoms of colorectal cancer. This includes indications for use, advice for patients in multiple languages and formats on completing the test and guidance for practices on how they can ensure test results are reviewed and actioned appropriately.

The Cancer Alliance is also monitoring the use of FIT by GP practices and primary care networks and will feedback to areas with low usage to try and improve uptake.

The inquest was told that interpretation of haemoglobin test results and prompt referral back into secondary care if they were abnormal and remained low despite treatment was important to effective and potentially lifesaving treatment. The volume of blood results that GPs were regularly having to consider was significant and made it difficult to always identify cases that were concerning. Prompts in relation to haemoglobin test may be effective in assisting GPs juggling a large volume of results.

To increase awareness of the significance of iron deficiency in diagnosis of cancer, the Cancer Alliance recently ran a webinar for primary care colleagues across Greater Manchester on cancer and anaemia. This webinar was recorded and is available on the Gateway C. They have also produced a short summary video and infographic which were shared with primary care practitioners and are available on the Gateway C website. The Cancer Alliance will ensure these are recirculated to primary care clinicians.

The Cancer Alliance is currently developing a series of clinical decision support tools within GP computer systems to encourage GPs to "think cancer" when certain codes are entered. A tool for iron deficiency anaemia will be prioritised as part of this work.

Actions taken or being taken to share learning across Greater Manchester.

1. Learning presented/shared with the Greater Manchester System Quality Group. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.

2. Shared learning from this and similar cases at Greater Manchester and borough level will be cascaded to professionals through relevant governance and learning forums.

In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.

I hope this response demonstrates to you and Mr. Flindle’s family that NHS GM has taken the concerns you have raised seriously and is committed to work together as a system including our service users, carers and families to improve the care provided.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.