Kai Takagi
PFD Report
Partially Responded
Ref: 2023-0502
Coroner's Concerns (AI summary)
Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's call-back system and informal handover process between shifts, leading to delayed care.
View full coroner's concerns
(1) Patients that leave the hospital Accident and Emergency
Responses
Noted
NHS England highlights existing national guidance and standards for following up on test results after discharge and refers to their urgent and emergency care recovery plan, noting the responsibility of Trusts to implement procedures and follow national guidance. (AI summary)
NHS England highlights existing national guidance and standards for following up on test results after discharge and refers to their urgent and emergency care recovery plan, noting the responsibility of Trusts to implement procedures and follow national guidance. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Kai Takagi who died on 14 June 2021. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 27 October 2023 concerning the death of Kai Takagi on 14 June 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Kai’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Kai’s care have been listened to and reflected upon. In your Report you raised the concern that patients that leave Accident and Emergency (A&E) departments with outstanding diagnostic test results are not followed up and tracked. Both NHS England and the Royal Colleges have published national guidance and standards for following up on test results following discharge from hospital, please see below: x NHS England, supported by the Academy of Medical Royal Colleges (AoMRC) published the Standards for the communication of patient diagnostic test results on discharge from hospital in March 2016. One of the guiding principles is that the clinician who orders the test is responsible for reviewing, acting and communicating the result and necessary actions to the patient and their GP, even if the patient has been discharged. x The Royal College of Pathologists (RCPath) published The communication of critical and unexpected pathology results in October 2017 which states that for ‘significant positive blood cultures for patients discharged from emergency departments, the principle of the result being the responsibility of the requester still holds’. x The Royal College of Emergency Medicine (RCEM) published Management of Investigation Results in the Emergency Department in May 2020. This clearly states that ‘All Emergency Departments should have a ‘Standard Operating Procedure’ for the handling of investigation results (radiological and non- radiological) that covers….those patients under the care of the Emergency Department, or discharged from the Emergency Department’. Your Report also raises that there is a risk posed to patients and call-backs, given the reliance on A&E Departments for routine out of hours health care. It is recognised that services across the NHS are currently facing significant pressures. NHS England is
committed to improving patient experience within hospitals and in January 2023 we published a two-year Delivery plan for recovering urgent and emergency care services. The plan aims to relieve pressures on emergency departments by: x Growing the workforce available for 111 online and urgent call services to offer support, advice, diagnosis and referral. x Expanding services within the community to prevent avoidable A&E admission. This will include more joined-up urgent care within the community and use of virtual wards. x Helping people access the right care first time, ensuring that 111 is the first port of call and reducing the need for people needing to go to A&E. x Growing capacity and number of beds within hospitals to relieve pressures on A&E Departments. It is the responsibility of Trusts to ensure that they have the necessary procedures and arrangements in place to follow national guidance. It will also be for the Trust to comment on your concerns surrounding their handover arrangements and the clinician led review into abnormal blood results. NHS England notes that you have also addressed your Report to Chelsea and Westminster Hospital. We will carefully consider their response to you which we have asked to be sighted on. I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action. 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.
committed to improving patient experience within hospitals and in January 2023 we published a two-year Delivery plan for recovering urgent and emergency care services. The plan aims to relieve pressures on emergency departments by: x Growing the workforce available for 111 online and urgent call services to offer support, advice, diagnosis and referral. x Expanding services within the community to prevent avoidable A&E admission. This will include more joined-up urgent care within the community and use of virtual wards. x Helping people access the right care first time, ensuring that 111 is the first port of call and reducing the need for people needing to go to A&E. x Growing capacity and number of beds within hospitals to relieve pressures on A&E Departments. It is the responsibility of Trusts to ensure that they have the necessary procedures and arrangements in place to follow national guidance. It will also be for the Trust to comment on your concerns surrounding their handover arrangements and the clinician led review into abnormal blood results. NHS England notes that you have also addressed your Report to Chelsea and Westminster Hospital. We will carefully consider their response to you which we have asked to be sighted on. I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action. 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.
Sent To
- Chelsea and Westminster Hospital
- NHS England
Response Status
Linked responses
1 of 2
56-Day Deadline
5 Feb 2024
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 30th and 31st August and 1st September 2023 evidence was heard touching the death of Kai TAKAGI. He died on 14th June 2021 aged 27 years.
Medical Cause of Death
I (a) Acute Peritonitis I (b) Perforated Gastric Ulcer
How, when, where Kai TAKAGI came by his death:
On 11th June 2021 Kai Takagi presented at Chelsea and Westminster Hospital Emergency Department with stomach ache and pain. Bloods were taken at the hospital and he was treated for gastritis and discharged home at about 2102. At 2106 shortly after discharge a blood result was received in the hospital emergency department indicating a high amylase level suggestive of acute pancreatitis. The plan was to contact Kai in the morning of 12th June 2021 with the result. This plan was handed over to the night shift and then to the morning shift doctors. Kai was not contacted by the hospital with the result as planned. No-one from the hospital asked him to return to the hospital for further examination or tests. On 14th June 2021 Kai was discovered by a work colleague at Kai’s apartment He had passed away in his apartment sometime between 2026 on 12th June 2021 and his discovery at 0938 on 14th June 2021” as a result of acute peritonitis from a perforated ulcer.
Conclusion of the Coroner as to the death:
Natural Causes Circumstances of the death:
Extensive evidence was heard by the court in the form of written and oral evidence, including expert evidence.
Of particular significance for the purpose of this report are the following matters:
(1) Kai was admitted to the Accident and Emergency Department of the Chelsea and Westminster Hospital, 369 Fulham Road, London on 11th June 2021 presenting with severe stomach pain. (2) A blood screen was ordered, and treatment commenced. (3) The treatment eased the symptoms of pain and Mr Takagi decided to leave the hospital around 2102hrs without receiving the blood result which, when received was indicative of acute pancreatitis. (4) The blood result was received shortly after Kai had left the hospital. A plan was made to call Kai back in the morning of 12th June 2021. Thereafter no-one from the hospital called him to give Kai the result or to ask him to return to the hospital which I found he would have done had he been called. (5) Kai was found dead on 14th June 2021 at his home. (6) For patients in hospital with abnormal blood results these will be captured by the medical handover and/or normal patient review or continuing care of the patient within the hospital. There is also now a book kept by the telephone in the department to record urgent abnormal results that are called through to the department from the lab. This book is checked regularly by the registrar in charge of the shift. (7) For patients that had left the hospital there was a system of call back of abnormal results to patients which depended on oral handover between shift Doctors. (8) There was a handover prompt sheet which had a small space to note those that had left and to act as a reminder to call them if a result needed to be notified to them. (9) There was safety-netting advice to advise the patient to return to hospital if their symptoms worsened. (10) It was accepted that this ring-back system was not the best. (11) I heard that some changes have already been made to the system to capture those that have left and needed to be called back with results, and further changes were being made to the system but they had not been fully implemented Matters of Concern: (1) Patients that leave the hospital Accident and Emergency Department with outstanding blood results or other diagnostic tests are not followed up and “tracked” in the same way that in-patients are, thus giving rise to the risk that they are missed and urgent follow-up care is not actioned or offered. (2) That as reliance on Accident and Emergency departments for routine out of hours health care increases, the burden of call back also increases on hospitals for patients who have left at a time when their departments are already over-stretched in dealing with admissions and those presenting to the department, thus increasing the risk that patients will not be called back for urgent follow-up assessment or treatment which may be life-saving. (3) That the system remains heavily dependent on oral handover, which is not amenable to independent audit as it assumes a person has done what was asked of them. Short of an individual doctor being asked if the call back had been actioned, there is no way of checking that it has. (4) That a periodic clinician led review of all abnormal blood results (and other test results), which the hospital has explored since I raised the matter in the hearing has not been fully implemented giving rise to the risk that patients who have left the hospital with potentially life-threatening conditions suggested by the tests may not be contacted urgently asking them to return thus increasing the risk of their untimely deaths.
Medical Cause of Death
I (a) Acute Peritonitis I (b) Perforated Gastric Ulcer
How, when, where Kai TAKAGI came by his death:
On 11th June 2021 Kai Takagi presented at Chelsea and Westminster Hospital Emergency Department with stomach ache and pain. Bloods were taken at the hospital and he was treated for gastritis and discharged home at about 2102. At 2106 shortly after discharge a blood result was received in the hospital emergency department indicating a high amylase level suggestive of acute pancreatitis. The plan was to contact Kai in the morning of 12th June 2021 with the result. This plan was handed over to the night shift and then to the morning shift doctors. Kai was not contacted by the hospital with the result as planned. No-one from the hospital asked him to return to the hospital for further examination or tests. On 14th June 2021 Kai was discovered by a work colleague at Kai’s apartment He had passed away in his apartment sometime between 2026 on 12th June 2021 and his discovery at 0938 on 14th June 2021” as a result of acute peritonitis from a perforated ulcer.
Conclusion of the Coroner as to the death:
Natural Causes Circumstances of the death:
Extensive evidence was heard by the court in the form of written and oral evidence, including expert evidence.
Of particular significance for the purpose of this report are the following matters:
(1) Kai was admitted to the Accident and Emergency Department of the Chelsea and Westminster Hospital, 369 Fulham Road, London on 11th June 2021 presenting with severe stomach pain. (2) A blood screen was ordered, and treatment commenced. (3) The treatment eased the symptoms of pain and Mr Takagi decided to leave the hospital around 2102hrs without receiving the blood result which, when received was indicative of acute pancreatitis. (4) The blood result was received shortly after Kai had left the hospital. A plan was made to call Kai back in the morning of 12th June 2021. Thereafter no-one from the hospital called him to give Kai the result or to ask him to return to the hospital which I found he would have done had he been called. (5) Kai was found dead on 14th June 2021 at his home. (6) For patients in hospital with abnormal blood results these will be captured by the medical handover and/or normal patient review or continuing care of the patient within the hospital. There is also now a book kept by the telephone in the department to record urgent abnormal results that are called through to the department from the lab. This book is checked regularly by the registrar in charge of the shift. (7) For patients that had left the hospital there was a system of call back of abnormal results to patients which depended on oral handover between shift Doctors. (8) There was a handover prompt sheet which had a small space to note those that had left and to act as a reminder to call them if a result needed to be notified to them. (9) There was safety-netting advice to advise the patient to return to hospital if their symptoms worsened. (10) It was accepted that this ring-back system was not the best. (11) I heard that some changes have already been made to the system to capture those that have left and needed to be called back with results, and further changes were being made to the system but they had not been fully implemented Matters of Concern: (1) Patients that leave the hospital Accident and Emergency Department with outstanding blood results or other diagnostic tests are not followed up and “tracked” in the same way that in-patients are, thus giving rise to the risk that they are missed and urgent follow-up care is not actioned or offered. (2) That as reliance on Accident and Emergency departments for routine out of hours health care increases, the burden of call back also increases on hospitals for patients who have left at a time when their departments are already over-stretched in dealing with admissions and those presenting to the department, thus increasing the risk that patients will not be called back for urgent follow-up assessment or treatment which may be life-saving. (3) That the system remains heavily dependent on oral handover, which is not amenable to independent audit as it assumes a person has done what was asked of them. Short of an individual doctor being asked if the call back had been actioned, there is no way of checking that it has. (4) That a periodic clinician led review of all abnormal blood results (and other test results), which the hospital has explored since I raised the matter in the hearing has not been fully implemented giving rise to the risk that patients who have left the hospital with potentially life-threatening conditions suggested by the tests may not be contacted urgently asking them to return thus increasing the risk of their untimely deaths.
Action Should Be Taken
It is for each addressee to respond to matters relevant to them.
Copies Sent To
Chief Executive, Chelsea and Westminster Hospital
Chief Executive NHS England
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