UK Inquiry Tracker

Nathan Mooney

PFD Report All Responded Ref: 2019-0072

Date of Report 26 February 2019

Coroner Chris Morris

Coroner Area Manchester (South)

Response Deadline est. 4 August 2019

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 4 Aug 2019

Coroner's Concerns (AI summary)

The report indicates general concerns were raised during the inquest, but specific details regarding the identified risks were not provided in the text.

View full coroner's concerns

In the circumstances it is my statutory duty to report to vou_

Responses

7 May 2019

Action Planned
Health Education England acknowledges the challenges of recruiting and retaining doctors. They mention a commitment to increasing medical school places and the development of a workforce implementation plan to address staffing and culture in the NHS. (AI summary)

View full response

Dear Sir, Re: Nathan Mooney Regulation 28 Report response write in response to your letter of 26 February 2019 addressed tct relating to your report made under the Coroners (Investigations) Regulations 2013 ("the Regulations") : As a recipient of the report; Health Education England (HEE) acknowledges its duty under regulation 29 of the Regulations to give a response to your report, with details of any action that has been taken or which it is proposed will be taken, or an explanation as to why no action is proposed. Upon reading your report; it is noted that you raise concerns about the care Mr Mooney received at Tameside General Hospital prior t0 his death in May 2017 . Specifically, you reference evidence given during your inquest regarding Tameside Integrated Care NHS Foundation Trust's medical workforce and measures which could alleviate pressures on workforce shortages: We write to respond to the points raised in your report that are relevant to HEE's statutory functions and remit; HEE is an Executive Non-Departmental Public Body sponsored by the Department of Health and Social Care (DHSC) , responsible for ensuring that the future clinical workforce is available in the right numbers and has the necessary skills, values and behaviours to meet patients' needs and deliver high quality care. The Care Act 2014 sets out HEE s remit and range of roles and responsibilities in detail, including its to ensure an effective system is in place for education and training in the NHS and public health system We note the evidence heard at the inquest regarding the challenges to recruit and retain doctors to substantive posts at the Trust: Ensuring we have sufficient supply of doctors across all grades and specialties is to excellent patient care. As set out in HEE's draft health and care workforce strategy for England in 2017 , the medical profession has seen the largest and most Developing people WAW hee nhsuk for health and enqurlesenhis net ONHS_HealtnEdEng healthcare duty key heer

NHS] Health Education England consistent growth of any profession. In addition, an extra 1,500 doctors a year will be trained in the NHS by 2020 in the biggest ever expansion of the medical workforce in England: We will use this expansion to target areas with the most need. We acknowledge (hat retention challenges can have an impact on the overall numbers of the medical workforce: However; as we do not directly employ NHS medical staff, it is a factor which falls outside of HEE's remit and responsibilities. In January 2019, the NHS Long Term Plan set out the direction to make the NHS workforce fit for the future. Going forward, we will continue to work closely with our partners across the system to plan how the NHS medical workforce can be further developed and meet patients' needs We acknowledge your reference to previous discussions on the implementation of a "tie-in" system for medical graduates, and note the views given at the inquest in relation to this such policy or response to the views given at the inquest relating to this would fall within DHSC's responsibility and as such HEE cannot comment further .

Sent To

Department of Health and Social Care

Response Status

Linked responses 1 of 1

56-Day Deadline 4 Aug 2019

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 1"June 2017,a inquest was opened into death of Mr Nathan Mooney who died on 23rd 2017 at Tameside General Hospital, Ashton-under-Lyne, aged 25 years. The investigation concluded at the end of the inquest which heard between 14h _ 17th January 2019_ At the end of the inquest, recorded a narrative conclusion that Mr Mooney died as a consequence of a known complication of previous abdominal surgery which was not identified by treating clinicians during his lifetime

Circumstances of the Death

Mr Mooney was essentially a fit and well gentleman: In 2015, he was diagnosed with a splenic cyst and elected to have spleen removed_ On 14th September 2015, Mr Mooney underwent a Splenectomy, in the course of which an iatrogenic defect was made to his diaphragm: This is a known complication of the surgery and one which was recognised at the time: The defect was repaired in the course of the operation Following recovery from the surgery, Mr Mooney did not experience any ongoing health problems: On 20th May 2017, Mr Mooney developed severe abdominal pain of sudden onset; which is likely to have resulted the diaphragmatic defect recurring, and his bowel becoming trapped in it: Mr Mooney attended Tameside General Hospital where he saw a locum Middle Grade doctor who referred him to the surgical team: The surgical team on duty in the hospital overnight on that occasion consisted of a locum Middle Grade surgeon, and a Senior House Officer who had completed a Foundation Year 2 surgical rotation at the hospital, but was also working a locum shift: The Senior House Officer reviewed Mr Mooney in conjunction with X-Rays which had been taken: The Senior House Officer formed the view that the X-Rays showed no abnormality, and discharged and the May his from

Mr Mooney with advice to return if symptoms did not improve or worsened. This decision was taken without recourse to a more senior doctor. A number of Mr Moonev' $ symptoms persisted over the following days and on 22nd May 2017,he attended his General Practitioner who after assessment and consultation with a senior colleague, decided to adopt a watch and wait approach, again giving advice to seek assistance if symptoms worsened. On 23rd 2017, Mr Mooney spoke to the General Practitioner by telephone following a clear deterioration in his condition: He collapsed at home whilst awaiting an emergency ambulance which conveyed him to hospital where he died despite attempts to resuscitate him: A post mortem examination determined Mr Mooney died as a consequence of:
1) a) Colonic herniation and perforation; b) latrogenic diaphragmatic defect; c) Elective splenectomy (splenic cyst - operated on 14" September 2015).

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action: It is apparent that at the time of Mr Mooney'$ care, Tameside General Hospital was heavily reliant on locum doctors to cover shifts_ The court heard evidence of measures which have been taken locally to recruit and retain doctors to substantive posts, however significant reliance on locum doctors remains an issue. The court heard evidence one of the Trust'$ Clinical Directors that this resulted from a lack of suitably skilled doctors in the UK labour market which in turn was compounded by a high attrition rate across a number of specialities whereby doctors do not complete their post graduate speciality training within the NHS (choosing instead, for example, to work overseas): In addition to obvious financial consequences of significant locum use for the NHS, the court heard that itcan impact adversely upon continuity of care, and militate against development of established and effective relationships between clinical teams: The Clinical Director expressed the view that the current position would be alleviated to a certain extent by implementation of a system whereby graduates of UK medical schools were (no doubt in consideration for financial or other support during training) tied-in to a specified period of NHS work following graduation. Whilst the Clinical Director was aware of previous discussions within the NHS about such a system, she was not aware of any plans to implement such a system: May from the

It is noted the previous Senior Coroner for this Area, John Pollard; had an exchange of correspondence with the former Under Secretary for Care Quality, Ben Gummer MP, in 2016 in which similar issues were raised.