Mark Jones
PFD Report
All Responded
Ref: 2022-0040
All 1 response received
· Deadline: 31 Mar 2022
Coroner's Concerns (AI summary)
Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent cases being missed.
View full coroner's concerns
1. During the inquest the Court was told that there is a backlog in standard referrals such as Mr Jones being seen. This means that a referral which pre Covid meant a waiting time of approximately 2.5 months for an outpatient appointment now involves a waiting time of approximately 8 months.
2. Mr Jones’ referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol in place between dentists and secondary care to provide for the routine provision of photographs to assist in triage. Such a protocol to ensure the provision of photographs by referring dentists in conjunction with more consistent provision of information would, the inquest was told, be helpful in improving the quality of triage and reduce the risk of patients needing urgent care being missed.
2. Mr Jones’ referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol in place between dentists and secondary care to provide for the routine provision of photographs to assist in triage. Such a protocol to ensure the provision of photographs by referring dentists in conjunction with more consistent provision of information would, the inquest was told, be helpful in improving the quality of triage and reduce the risk of patients needing urgent care being missed.
Responses
Action Planned
The Chief Dental Officer will reinforce the importance of good referral practice in future communications on oral cancer to the dental profession and commissioners, and will cascade similar communication and guidance to NHS general medical practitioners. (AI summary)
The Chief Dental Officer will reinforce the importance of good referral practice in future communications on oral cancer to the dental profession and commissioners, and will cascade similar communication and guidance to NHS general medical practitioners. (AI summary)
View full response
Dear Ms Mutch,
Thank you for your letter of 9 February 2022 about the death of Mark Jones. I am replying as Minister of State for Social Care, and I thank you for the additional time allowed.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Jones’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.
In preparing this response, Departmental officials have made enquiries with NHS England, as well as the relevant regulator in this case, the Care Quality Commission. There are three main issues in your report to respond to from a national perspective.
You may wish to know that the guidance on the referral of patients with suspected cancer from dental services into secondary care services is included in the National Institute for Health and Care Excellence guideline (NG12) Suspected cancer: recognition and referral1. Section 1.8 makes it clear that, where the symptoms described in the oral cavity are observed, dentists should consider referring a patient through an urgent referral, which would normally mean that the patient is seen within two weeks.
This advice is reinforced in the guidance to NHS commissioners on Commissioning Oral Surgery and Oral Medicine2. This document describes the services that should be provided, along with minimum standard specification for the commissioning of these services. It states on page 20 that: “if an oral cancer is suspected or there is a suspicious head and neck (includes salivary gland) mass etc., the patient should be referred as per (2 week) Cancer Referral Pathway wait criteria to a head and neck oncology service.”
The Chief Dental Officer (CDO) has regularly emphasised the importance of this guidance. By way of example, the May 2021 Dental Bulletin3 focused on mouth cancer and included a leaflet on mouth cancer awareness for dental teams.
Secondly, the expected referral route into Head and Neck Teams for dentists is via one of two NHS commissioned e-referral systems for dental practitioners. Both NHS online e-referral
1 https://www.nice.org.uk/guidance/ng12 2 https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/09/guid-comms-oral.pdf 3 http://createsend.com/t/d-50A7FF9BB4BF31622540EF23F30FEDED
portal systems contain information regarding oral cancer and suspected lesions, and the necessity to follow the urgent referral pathway, with further guidance on minimum data set and imaging. The FDS system is used in the Manchester area and includes the ability to draw the lesion relative to key head and neck landmarks to assist the triage judgments of the urgency and appropriate receiving service of in the absence of a photograph4.
The online portals specification and data/imaging requirements are based on the National Guidance5 to NHS Commissioners on Commissioning Oral Surgery and Oral Medicine and reflects the requirement, and the important point that you raised, about images to accompany a referral by dentists into secondary care. The Patient Journey set out on page 55 of the National Guidance makes it clear that: “Appropriate clinical images and radiographs to support diagnosis; ideally these should be in digital format.” This requirement is reinforced in many areas though local guidance or local referral practice issued by local commissioners to their system6.
The content of an effective referral is also reinforced in professional guidance published by the College of General Dentistry (formerly the Faculty of General Dental Practice (UK))7. Section 2.3 on Making and Receiving Referrals (page 10) again makes it clear that referrals should be accompanied by appropriate images.
In the light of your recommendation, the Chief Dental Officer (CDO) will again reinforce the importance of good referral practice in future communications on oral cancer to the dental profession and commissioners. In addition, she has recommended that the NHS cascades similar communication and guidance to NHS general medical practitioners who account for the vast majority of cases referred to Head and Neck centres.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
HELEN WHATELY
4 https://www.dental-referrals.org/dentists/cancer/ 5 https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/09/guid-comms-oral.pdf 6 https://www.dental-referrals.org/wp-content/uploads/2017/12/final-NHS-ORAL-CANCER-CARE-with- Acknowledgements.pdf
v0.8.pdf
7 https://cgdent.uk/wp-content/uploads/2021/08/Standards-in-Dentistry-2018-text.pdf
Thank you for your letter of 9 February 2022 about the death of Mark Jones. I am replying as Minister of State for Social Care, and I thank you for the additional time allowed.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Jones’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.
In preparing this response, Departmental officials have made enquiries with NHS England, as well as the relevant regulator in this case, the Care Quality Commission. There are three main issues in your report to respond to from a national perspective.
You may wish to know that the guidance on the referral of patients with suspected cancer from dental services into secondary care services is included in the National Institute for Health and Care Excellence guideline (NG12) Suspected cancer: recognition and referral1. Section 1.8 makes it clear that, where the symptoms described in the oral cavity are observed, dentists should consider referring a patient through an urgent referral, which would normally mean that the patient is seen within two weeks.
This advice is reinforced in the guidance to NHS commissioners on Commissioning Oral Surgery and Oral Medicine2. This document describes the services that should be provided, along with minimum standard specification for the commissioning of these services. It states on page 20 that: “if an oral cancer is suspected or there is a suspicious head and neck (includes salivary gland) mass etc., the patient should be referred as per (2 week) Cancer Referral Pathway wait criteria to a head and neck oncology service.”
The Chief Dental Officer (CDO) has regularly emphasised the importance of this guidance. By way of example, the May 2021 Dental Bulletin3 focused on mouth cancer and included a leaflet on mouth cancer awareness for dental teams.
Secondly, the expected referral route into Head and Neck Teams for dentists is via one of two NHS commissioned e-referral systems for dental practitioners. Both NHS online e-referral
1 https://www.nice.org.uk/guidance/ng12 2 https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/09/guid-comms-oral.pdf 3 http://createsend.com/t/d-50A7FF9BB4BF31622540EF23F30FEDED
portal systems contain information regarding oral cancer and suspected lesions, and the necessity to follow the urgent referral pathway, with further guidance on minimum data set and imaging. The FDS system is used in the Manchester area and includes the ability to draw the lesion relative to key head and neck landmarks to assist the triage judgments of the urgency and appropriate receiving service of in the absence of a photograph4.
The online portals specification and data/imaging requirements are based on the National Guidance5 to NHS Commissioners on Commissioning Oral Surgery and Oral Medicine and reflects the requirement, and the important point that you raised, about images to accompany a referral by dentists into secondary care. The Patient Journey set out on page 55 of the National Guidance makes it clear that: “Appropriate clinical images and radiographs to support diagnosis; ideally these should be in digital format.” This requirement is reinforced in many areas though local guidance or local referral practice issued by local commissioners to their system6.
The content of an effective referral is also reinforced in professional guidance published by the College of General Dentistry (formerly the Faculty of General Dental Practice (UK))7. Section 2.3 on Making and Receiving Referrals (page 10) again makes it clear that referrals should be accompanied by appropriate images.
In the light of your recommendation, the Chief Dental Officer (CDO) will again reinforce the importance of good referral practice in future communications on oral cancer to the dental profession and commissioners. In addition, she has recommended that the NHS cascades similar communication and guidance to NHS general medical practitioners who account for the vast majority of cases referred to Head and Neck centres.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
HELEN WHATELY
4 https://www.dental-referrals.org/dentists/cancer/ 5 https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/09/guid-comms-oral.pdf 6 https://www.dental-referrals.org/wp-content/uploads/2017/12/final-NHS-ORAL-CANCER-CARE-with- Acknowledgements.pdf
v0.8.pdf
7 https://cgdent.uk/wp-content/uploads/2021/08/Standards-in-Dentistry-2018-text.pdf
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
31 Mar 2022
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 16th November 2020 I commenced an investigation into the death of Mark Jones. The investigation concluded on the 22nd December 2021 and the conclusion was one of Narrative: Died from the complications of necessary surgery. The medical cause of death was 1a Haemorrhage from tongue following surgery for squamous cell carcinoma
Circumstances of the Death
Mark Deardon Jones was diagnosed with squamous cell carcinoma of the tongue. He underwent complex surgery to treat his cancer including a left hemiglossectomy of the tongue. He was discharged home on 12th November 2020. On 13th November 2020 he had a catastrophic haemorrhage at the site of the hemiglossectomy and died at his home address
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.