Dear Ms Hayes

Regulation 28 Report to Prevent Future Deaths – Lady Lola Kay Crouch

I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated 21 February 2025, relating to the Inquest of Lady Lola Kay Crouch.

We have considered your concerns and set out our formal response to each matter using your numbering as follows.

Matters of Concern

(1) Lady Lola was not informed of the findings of potential malignancy from a CT scan in December 2022. This was not followed up and was then not given as part of the history when Lady Lola attended hospital in February 2023.

We acknowledge that patients should always receive full, timely and accurate information about their imaging results, and it is our responsibility to share this information with them to deliver excellent care.

Our policy ‘Communication of time critical or unexpected significant findings during diagnostic reporting’ MSEPO-21240’ makes clear that the referring clinician is responsible for the review of any radiology they request. Where radiological imaging reports detect an unexpected, significant or time sensitive finding, our policy provides that a radiology alert is sent to the responsible consultant with the full report so that prompt action can be taken, including communication with the patient.

Our policy details the expectations around communication of radiology results in the broadest sense, including verbal discussions with staff, recording key information in the patient record, and if appropriate, raising alerts to share with other professionals including primary care. Our policy is subject to annual audit to monitor compliance and effectiveness.

This process provides assurance that diagnostic imaging is reviewed by the right person in a timely manner to inform clinical decision making and facilitate patient communication of possible diagnosis.

As part of our digital improvement innovation project, we have signed up to the ‘NHS App’ radiology reporting service whereby patients now receive a copy of their own imaging reports to their personal NHS App. The reports include a summary of clinical findings that can be read by patients to improve communication and understanding of their own health record.

I am advised by my surgical colleagues that presentations to the Emergency Department (ED) with signs and symptoms of bowel obstruction, particularly small bowel obstruction, have a variety of differential diagnoses. As in Lady Lola’s case, with a background of multiple previous complex open operations, adhesions are the leading cause of small bowel obstruction.

Lady Lola had a short presenting history and a CT scan suggestive of small bowel obstruction with differential diagnoses, but suggestive of adhesive obstruction as the most likely cause. Taking all these features into account and coupled with the fact that her symptoms completely resolved within two days of conservative management alone, this would be suggestive of adhesive small bowel obstruction.

Further, full resolution of Lady Lola’s symptoms for two months subsequent to an ED presentation would also be a highly unexpected outcome in a case of malignant small bowel obstruction. When discussing results with any complex, unwell surgical patient in the emergency setting, scan results could be poorly communicated or misunderstood.

It has been recognised that further investigation and information for the patient would have been appropriate in this case and this learning has been shared across the general surgical team through morbidity and mortality meeting discussion.

(2) Staffing levels – A Medical Emergency call was not triggered overnight on the surgical ward when elevated NEWS scores required medical review that was escalated but delayed due to doctor staffing levels.

Our ‘NEWS2’ escalation policy was in place at the time of Lady Lola’s attendances. The outcome of Lady Lola’s case was communicated at both our July 2024 and August 2024 general surgical audit meetings to share learning. During the meetings we highlighted the importance of compliance with the NEWS2 escalation policy again and reminded the surgical staff about the role of the trigger response team, and our local departmental escalation process. The trigger response and hospital out of hours team are automatically notified by the electronic observation system, NEWS escalations and attend the unwell patient.

Since Lady Lola’s case we have established the hospital out of hours service in the surgical department to provide a more robust response to the surgical wards. This process has been in place for other specialties previously and we know it works very well.

Along with the hospital wide trigger response team and hospital out of hours service, this provides the surgical team, with senior nursing support who can provide the more junior surgical resident with clinical support, vascular access, resuscitative support, and escalation prompting. We have further reiterated the NEWS and local clinical escalation process to the new residents as part of our standard induction process.

In terms of staffing, we have a policy that clearly identifies the actions required to address unfilled junior doctor rota gaps. This involves enacting the acting down policy: ‘Unforeseen duties – Consultant, MSEPO21041’. Where we have unfilled junior doctor gaps in the rota that cannot be filled, the Consultant and Registrar for general surgery and urology will act down to ensure that sufficient support is provided.

We have implemented the necessary changes to ensure that patients are properly informed of their imaging results, and embedded new processes within our surgical teams to make sure surgical colleagues are well supported overnight for urgent cases and when required the Consultants act down as per policy.

I am assured that we have appropriately addressed your concerns in this case, however if I can assist further with these matters, please do not hesitate to contact me.