Michael Daft
PFD Report
All Responded
Ref: 2023-0475
All 1 response received
· Deadline: 19 Jan 2024
Coroner's Concerns (AI summary)
There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for patients on multiple treatment pathways.
View full coroner's concerns
The MATTER OF CONCERN is as follows –
• There is little evidence to date of effective communication between Multi-Disciplinary Teams (MDT) from different specialisms when a patient is on more than one treatment pathway.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
• There is little evidence to date of effective communication between Multi-Disciplinary Teams (MDT) from different specialisms when a patient is on more than one treatment pathway.
In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action.
Responses
Action Planned
The trust is developing an updated Infoflex system for MDT coordinators, holding regular MDT excellence meetings, and providing monthly updates to Divisional Management Teams. An MDT Oversight Group will be established in February 2024 to review the project status. (AI summary)
The trust is developing an updated Infoflex system for MDT coordinators, holding regular MDT excellence meetings, and providing monthly updates to Divisional Management Teams. An MDT Oversight Group will be established in February 2024 to review the project status. (AI summary)
View full response
Dear Miss Wood
Inquest: - Michael Daft- Prevention of Future Death Report [PFDR] Response
I am writing in my capacity as Medical Director of Nottingham University Hospitals NHS Trust in response to the Prevention of Future Deaths Notice issued on 24th November 2023 following the sad death of Mr Michael Daft. May I begin with offering my sincerest condolences to Mr Daft’s family for their loss. I am deeply sorry for the missed opportunities and issues that were highlighted during the Inquest. The concerns you have raised have been taken extremely seriously. Please find attached a commentary in response to the Prevention of Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the inquest into the death of Mr Daft. My response to the concerns identified in the PFD report have been informed following work undertaken by colleagues within the Patient Safety Teams, Surgical and Cancer and Associated Specialties (CAS) Divisions and the Cancer Centre Team.
The actions either taken or planned in response to the learning from the inquest are summarised below. The oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight - Committees of our Board will receive a progress report. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust.
Inquest: - Michael Daft- Prevention of Future Death Report [PFDR] Response
I am writing in my capacity as Medical Director of Nottingham University Hospitals NHS Trust in response to the Prevention of Future Deaths Notice issued on 24th November 2023 following the sad death of Mr Michael Daft. May I begin with offering my sincerest condolences to Mr Daft’s family for their loss. I am deeply sorry for the missed opportunities and issues that were highlighted during the Inquest. The concerns you have raised have been taken extremely seriously. Please find attached a commentary in response to the Prevention of Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the inquest into the death of Mr Daft. My response to the concerns identified in the PFD report have been informed following work undertaken by colleagues within the Patient Safety Teams, Surgical and Cancer and Associated Specialties (CAS) Divisions and the Cancer Centre Team.
The actions either taken or planned in response to the learning from the inquest are summarised below. The oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight - Committees of our Board will receive a progress report. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients across the Trust.
Sent To
- Nottingham University Hospitals NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
19 Jan 2024
All responses received
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 23rd of November 2022, I commenced an investigation into the death of Michael David Daft. The investigation concluded at the end of the inquest on the 22nd of November 2023. The conclusion of the inquest was natural causes.
Circumstances of the Death
Michael was diagnosed with rectal cancer on the 30th of July 2021. A left renal mass was also identified, and further tests had to be undertaken to identify its cause. There were delays in establishing the renal diagnosis and the colorectal surgery was postponed until the outcome of that was known. A diagnosis of renal cell carcinoma was confirmed on the 5th of November 2021 and the necessary surgery for both conditions was planned for the 3rd of December 2021 but was cancelled due to no HDU bed. Further scans identified a progression of the rectal cancer and Michael was referred to Oncology for treatment, which commenced in January 2022. Michael’s cancer did not respond to treatment, and he was admitted to hospital on the 8th of November. He deteriorated rapidly and died on the 10th of November 2022, at City Hospital, Nottingham, from a perforated bowel, secondary to tumour progression. Detailed findings as to how he came by his death are described within a written Determination dated 22nd of November 2023, appended to this report.
Copies Sent To
2. The Nottingham University Hospital Trust (NUH)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.