UK Inquiry Tracker

Elizabeth Self

PFD Report All Responded Ref: 2018-0308

Date of Report 29 October 2018

Coroner Christopher Dorries

Coroner Area South Yorkshire (West)

Response Deadline ✓ from report 15 January 2019

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 15 Jan 2019

Coroner's Concerns (AI summary)

Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to remain unattended for hours, leading to significant delays in diagnosis.

View full coroner's concerns

am satisfied that the hospital in question has taken appropriate and significant remedial action and do not therefore find it necessary to address this report to the hospital itself: However; my concern is that this situation can arise elsewhere which is why address this report to NHS England: as set out in my closing remarks (attached), that is to say a) moderately senior doctor had put in not one but two X-ray requests that had to be rejected which is suggestive of a lack of necessary training b) A valid CT request had laid unattended for a full morning, the reasons for which were never established but the hospitals own investigation report team formed an impression of a breakdown in communications_ c) The overall circumstances were such that neither requests was actually completed until more than thirteen hours after what was a significant fall: The inquest found this to be a criticism of the system then in place rather than of particular individuals. In essence my concern is that those inspecting hospitals in other places should include in their programme establishing that senior staff do actually know how to make a proper X-ray request which will not therefore be rejected and checking systems to ensure that X-ray and CT requests cannot go for a period of hours without resolution:

Responses

NHS England NHS / Health Body

30 Oct 2018

Action Planned
NHS England acknowledges the concerns and states they have been working with hospitals to improve standards of care provided to patients under the seven-day services programme, including access to diagnostic imaging. They will disseminate learning from this case through quality structures across England and are undertaking a national review of vaccination and immunisation arrangements. (AI summary)

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Dear Mr Dorries Regulation 28 report in relation to Mrs Elizabeth Glen Self (deceased) write in response to the above report sent to NHS England on 30th October 2018. Firstly, would like to apologise to the family of Mrs Self and yourself for the delay in this response. Whilst it is not an excuse_ we have been in period of significant organisational change and this has delayed the response would like to offer my condolences to the family of Mrs Self and apologise for any added distress this has caused. note that you have been satisfied that the trust has ensured appropriate learning has been taken to ensure this situation does not arise again. You have asked NHS England and Improvement to ensure that those inspecting hospitals should ensure gain assurance that senior staff are aware of the appropriate process and method to request urgent radiology requests and that trusts have a process in place to ensure urgent requests are reviewed in a timely manner_ Inspection of hospitals is undertaken by the Care Quality Commission (CQC) and note have received a copy of the notice: The CQC's regulatory function is independent of NHS Englandllmprovement, so am not in position to require response from them in relation to this matter. NHS Englandllmprovement have however been working with hospitals to improve standards of care provided to patients under the day services programme: This includes ready access to appropriate diagnostic imaging which would be relevant to this case_ Further details of this programme can be found at https llimprovement nhs uk/resourceslseven-day_servicesltth2-the-four-priority-standards NHS England and Improvement has responsibility for quality oversight and assurance and will ensure this matter: and the learning that can be taken it is disseminated through quality structures across England.

Sent To

NHS England

Response Status

Linked responses 1 of 1

56-Day Deadline 15 Jan 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

In November 2017 commenced an investigation into the death of Mrs Elizabeth Glen Self. The investigation concluded following an inquest in June 2018 where the narrative conclusion set out that: Mrs Self was admitted to hospital on 11th April 2017 following a heart attack: The court finds it more likely than not the she would have survived this episode. Unfortunately Mrs Self suffered a serious fall in hospital when she became entangled in a line attached to her left this left her with serious injuries which were not immediately recognised. Necessary scans and X-ray examinations were ordered some hours later but did not take place for another nine hours Or SO. The court has closely considered these most regrettable delays but the expert advice is that a faster response either in investigation or transfer to Sheffield would probably have saved Mrs Self' $ life:

Circumstances of the Death

The circumstances of the death are set out in the narrative conclusion shown above. In addition attach a copy of my closing remarks which is just a single sheet In summary, this lady with severe heart disease suffered a fall in hospital. She was unlikely to survive from that onwards but there was a in dealing with two X-ray requests and one CT request of more than thirteen hours_ being leg, not point delay

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe you; the named authorities, have the power to take such action.