30th March 2020

Dear Mr The late Peter Edward SMITH deceased write further to you email dated February 2020 enclosing regulation 28 report to prevent future deaths_ am pleased to provide a response to your report addressing your concerns surrounding the death of Peter Smith. Recorded Circumstances of the Death "On 29th September 2018 a chest X-ray indicated a potential left upper zone abnormality resulting in a CT scan being performed on 22nd November 2018 and a PET scan on 27th December 2018. Subsequent tests and investigations lead to a date for surgery on 26th February 2019. Time was' of the essence but by then surgery was no longer possible. The deceased relapsed on 2Oth February and died on the 4th March
2019. Coroner's Concerns "During the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you: The MATTERS OF CONCERN are as follows: til Ellery

There was a significant delay in the diagnosis and treatment of Mr Smith's adenocarcinoma which contributed to his death on the 4h March 2019. Time was of the essence, but tests, reports, appointments and discussions took place consecutively to the extent that by the time a final date for surgery was fixed it was no longer possible.
3. Had tests been conducted expeditiously and concurrently with predictable tests organised in advance it is likely that the surgery would have been able to take place significantly earlier than it did. Although separate Trusts were effectively treating Mr Smith's adenocarcinoma as one You reported this matter under paragraph Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Action Taken The University Hospitals of North Midlands NHS Trust [UHNM] has taken the issues highlighted during the inquest seriously and am grateful to you for raising potential areas for improvement: The thoracic surgery department at UHNM provides surgical service to the Shrewsbury and Telford Hospital NHS Trust [SaTH] for patients with intra-thoracic problems needing surgery, including lung cancer_ With regard to the in the diagnosis and treatment of Mr Smith's adenocarcinoma SaTH has produced, in conjunction with and agreed by the UHNM visiting cardiothoracic surgeons, the attached Standard Operating Procedure [SOP] "Referral for surgical resection of proven or suspected lung cancer" SaTH has implemented the SOP and will be responding to you separately sincerely hope that this report provides you with assurance that UHNM [and SaTH] have taken the matters arising from the inquest of the late Peter Smith seriously The Trust strives to provide high standard of care to all patients and am grateful to you for raising these matters on this occasion and for the opportunity for us to review our processes_ should like to extend my condolences to the family of Mr Smith and my sincere apologies that Mr Smith didn't receive the standard of care at the end of his life that he deserved. Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly: