Michael Robert Collins
PFD Report
All Responded
Ref: 2021-0092
All 1 response received
· Deadline: 26 May 2021
Coroner's Concerns (AI summary)
The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical report delivery poses a significant communication risk.
View full coroner's concerns
The Inquest heard evidence that the current CERNER system does not always ensure that results are sent through to the referring clinician: The Inquest heard evidence of a "quirk" in the system whereby results will be sent through to doctors who have no involvement in the patient's care. The Inquest heard evidence that radiologists can now drop reports into a folder where there are unexpected and significant radiological findings. There is a specific folder relating to the finding of abdominal aortic aneurysms. The radiologist however raised a concern at the Inquest that it is not easily apparent to the reporting radiologist that the report has reached the appropriate clinician.
Responses
Action Taken
The respiratory team developed a Standard Operating Procedure to ensure all investigation results are reviewed promptly. The trust Divisional Director for Imaging has reviewed the processes and has improved the system, which is now formally incorporated within the trust Standard Operating Procedure. (AI summary)
The respiratory team developed a Standard Operating Procedure to ensure all investigation results are reviewed promptly. The trust Divisional Director for Imaging has reviewed the processes and has improved the system, which is now formally incorporated within the trust Standard Operating Procedure. (AI summary)
View full response
Dear Ms Persaud RE: Regulation 28: Report to Prevent Future Deaths
I write in response to the recent Regulation 28: Report to Prevent Future Deaths notice regarding the care of Michael Robert Collins. First, thank you very much for granting us an extension to provide a response, in recognition of the pressures brought by the second COVID surge. Michael Collins was referred by his GP to the respiratory team on 06/12/2016, after a chest x-ray report suggested a computed tomography (CT) scan should be performed for better evaluation of the chest. Referral triaged by the respiratory team on 13/12/16 and a CT scan was requested. The CT scan was performed and reported in January 2017, diagnosing an ascending thoracic aortic dilatation, supra-renal aortic dilatation and an infra-renal aortic aneurysm.
The findings within this report were not acted upon by the requesting team until Mr Collins was seen in clinic in August 2017, when his GP was informed. Mr Collins was referred by his GP to the vascular service in September 2017. There were delays to his appointment process due to human error and he was eventually seen in the vascular clinic in February 2018.
Following discussion in the combined aorto-vascular MDT on 14/03/18, Mr Collins was referred to a different vascular team. On 06/04/18, at 14:00hs, a CT of the abdomen (CTA) was performed showing an aneurysm of 7.0 cm with no leak or rupture. On the way home from the hospital appointment Mr Collins had a cardiac arrest and was brought to the Emergency Department at RLH around 17:00 but sadly died..
The matters of concern raised in the Regulation 28 notice were:
1. The inquest heard that the CERNER system does not always ensure that results are sent to the requesting clinician, and that results are sometimes sent to doctors who have no involvement in the patient’s care.
2. The inquest heard that radiologists can drop reports into a folder which contains unexpected and significant findings, but it is not easily apparent to the reporting radiologist that the report has reached the appropriate clinician.
Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES
Telephone:
Chief Medical Officer
Regarding the first matter of concern The respiratory team have developed a Standard Operating Procedure to ensure that all investigation results are reviewed promptly, including when the person who requested the investigation is not at work.
Regarding the second matter of concern The trust Divisional Director for Imaging has reviewed the processes used to notify unexpected and significant findings in consultation with the Clinical Director for Imaging at Whipps Cross. The system has been improved and is now formally incorporated within the trust Standard Operating Procedure.
Thank you for communicating your concerns to us - we believe that our hospital is safer as a result of the action we have taken to address them.
I write in response to the recent Regulation 28: Report to Prevent Future Deaths notice regarding the care of Michael Robert Collins. First, thank you very much for granting us an extension to provide a response, in recognition of the pressures brought by the second COVID surge. Michael Collins was referred by his GP to the respiratory team on 06/12/2016, after a chest x-ray report suggested a computed tomography (CT) scan should be performed for better evaluation of the chest. Referral triaged by the respiratory team on 13/12/16 and a CT scan was requested. The CT scan was performed and reported in January 2017, diagnosing an ascending thoracic aortic dilatation, supra-renal aortic dilatation and an infra-renal aortic aneurysm.
The findings within this report were not acted upon by the requesting team until Mr Collins was seen in clinic in August 2017, when his GP was informed. Mr Collins was referred by his GP to the vascular service in September 2017. There were delays to his appointment process due to human error and he was eventually seen in the vascular clinic in February 2018.
Following discussion in the combined aorto-vascular MDT on 14/03/18, Mr Collins was referred to a different vascular team. On 06/04/18, at 14:00hs, a CT of the abdomen (CTA) was performed showing an aneurysm of 7.0 cm with no leak or rupture. On the way home from the hospital appointment Mr Collins had a cardiac arrest and was brought to the Emergency Department at RLH around 17:00 but sadly died..
The matters of concern raised in the Regulation 28 notice were:
1. The inquest heard that the CERNER system does not always ensure that results are sent to the requesting clinician, and that results are sometimes sent to doctors who have no involvement in the patient’s care.
2. The inquest heard that radiologists can drop reports into a folder which contains unexpected and significant findings, but it is not easily apparent to the reporting radiologist that the report has reached the appropriate clinician.
Trust Executive Office Ground Floor Pathology and Pharmacy Building The Royal London Hospital 80 Newark Street London E1 2ES
Telephone:
Chief Medical Officer
Regarding the first matter of concern The respiratory team have developed a Standard Operating Procedure to ensure that all investigation results are reviewed promptly, including when the person who requested the investigation is not at work.
Regarding the second matter of concern The trust Divisional Director for Imaging has reviewed the processes used to notify unexpected and significant findings in consultation with the Clinical Director for Imaging at Whipps Cross. The system has been improved and is now formally incorporated within the trust Standard Operating Procedure.
Thank you for communicating your concerns to us - we believe that our hospital is safer as a result of the action we have taken to address them.
Sent To
- Royal London Hospital
Response Status
Linked responses
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56-Day Deadline
26 May 2021
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 16th October 2019 commenced an investigation into the death of Michael Robert Collins: The investigation concluded at the end of the Inquest on the 22nd October 2020. The conclusion of the Inquest was a conclusion of natural causes
Circumstances of the Death
In November 2016 Mr Collins presented to his GP with shortness of breath: He underwent a chest xray which revealed abnormalities. He was referred to the chest clinic and underwent a chest CT scan on 17 January 2017. The CT scan of January 2017 revealed an abdominal aortic aneurysm of 4.9cm: The finding of the abdominal aortic aneurysm was not highlighted to the referring team by the radiologist: Mr Collins was seen in the chest clinic on 2 February 2017_ The CT scan was noted by the respiratory consultant; but she took no steps to request a referral to the vascular surgeons. No letter was sent to the GP to report the findings at clinic or findings of the CT scan. Whilst the 4.9cm aneurysm would not have required surgical intervention, it would have required ongoing monitoring: On the 2 August 2017 Mr Collins was seen by the respiratory physician who wrote an "urgent' letter to the GP requesting that the GP make a referral to the vascular team: The letter was dictated on the 14 August 2017 and received in the GP surgery on 22 August 2017. The respiratory physician could have made a direct referral to the vascular team, in light of the delay in acting on the January 2017 scan report: This was not done: The GP made a referral to the vascular team on the 7 September 2017. The referral was erroneously directed by the receiving vascular surgeon to the cardiothoracic team_ Mr Collins should have been seen by a vascular surgeon within 8 weeks (by the 7 November 2017) Instead,he was seen by a cardio-thoracic and surgeon on the 26 February 2018 A further CT scan was directed and review by the vascular surgeon was requested on 14 March 2018_ Mr Collins attended the CT scan on the 6 April 2018. The CT scan showed an abdominal aortic aneurysm of 7cm: Mr Collins very sadly passed away at Whipps Cross Hospital, following the scan on the 6 April 2018. He died as a result of a ruptured abdominal aortic aneurysm. The evidence revealed that surgical intervention was not indicated for Mr Collins in light of his co-morbidities No other action could have been taken to avoid the risk of rupture: Mr Collins' death could not therefore have been avoided.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.