Roy Millar
PFD Report
Historic (No Identified Response)
Coroner's Concerns (AI summary)
Ward administrators in the Neurology Department were unaware of their responsibility to book follow-up appointments, leading to a large number of patients, including the deceased, not having appointments booked; a review revealed 146 patients did not have follow-up appointments booked.
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PHNT instigated a Root Cause Analysis following this incident; a copy of which is enclosed. Ithe author of the Report and the Trust's Patient Safety Lead, attended the Inquest: During the course of the hearing emerged that the Ward Administrator in the Neurology Department had been recently appointed. She had been trained by her predecessor. Neither the previous nor the current Ward Administrator were aware of their responsibility to book follow-up appointments for patients who had been discharged: Their understanding was that appointments would be arranged by Consultants' secretaries and it seems apparent that a large number of appointments were made in this way: Derriford Park; Derriford Business Purk; Ply mouth; PL6 5Q7 Tel 01752 204636 Fax aged The from put biopsy being emerged during the course of the Inquest that the Ward Administrators in the Neurology Department had not booked follow-up appointments for approximately 26 months. As you will see from the enclosed Root Cause Analysis, PHNT has reviewed 1000 patient admissions and it has revealed that 146 patients die not have follow-up appointments booked. In Mr Millar's case the evidence heard was that had the follow-up scan been conducted in June 2015 this was likely to have led to a biopsy which would have diagnosed the brain tumour: If Mr Millar had undergone earlier surgery, the Inquest heard that he would have had a 50% chance of surviving for a year:
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56-Day Deadline
8 Nov 2016
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 29 September 2015 commenced an investigation into the death of Roy Gordon Millar The investigation concluded at the end of an inquest on 12 September 2016. The conclusion of the inquest was that Mr Millar died from Natural Causes. medical cause of death was given as (a) Seizure and Brain Swelling; (b) Glioblastoma
Circumstances of the Death
Mr Millar attended the E Department of Plymouth Hospitals NHS Trust (PHNT) on February presenting with slurred speech and right facial droop. He had a CT Scan: At a Ward round on 9 February an MRI Scan was requested. Review of both scans revealed a subtle area of abnormality on the right temporal lobe of Mr Millar's brain: The Consultant requested that a further MRI scan with contrast be performed in 4 weeks time with medical review in 8 weeks time The repeat MRI scan was performed on 8 March 2015. Unfortunately the results of the scan were not sent to the correct Consultant with the consequence that a recommendation for further scan in 3 months time was not followed up. The Out-Patient appointment the Consultant requested in 8 weeks the February admission was not into being: This was due to reasons that are explained further below: On 10 August 2015 Mr Millar re-presented to PHNT with more severe facial droop. A tumour was identified. After review by a Neurosurgeon it was arranged for Mr Millar to undergo a and debulking procedure: Unfortunately Mr Millar died on the date fixed for the operation 25 August 2015
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you as the Secretary of State for Health have the power to take such action: The Inquest heard of the changes that have been made within PHNT. Ward Administrators now receive formal training when appointed. formal Ward Clerk Training Manual has been produced. A regular Ward Clerk Forum has been set up that meets monthly: The relevant administrative practice note (APN) of which the former and current Ward Administrators were unaware has been re-circulated on three occasions was satisfied at the conclusion of the Inquest that there were no additional steps the Trust could reasonably be expected t0 take to prevent similar fatalities in the future. was concerned, however, that the difficulty revealed by this investigation could easily be happening in other Trusts across the Country: It is for this reason that write to you in order that the learning that has come out of this Inquest can be shared nationally if you feel that to be appropriate: am further copying this letter to the Care Quality Commission who, as you will know, are tasked with the inspection of Hospitals_ The difficulties that occurred with the fixing of Out-Patient appointments in the Neurology Department were not picked up by CQC as suspect their inspections simply were not intended to detect such problem: In bringing this issue to the attention of the
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Patient appointments booked as anticipated. If any of those patients have died prematurely as a consequence of any in their treatment; it seems to me that those deaths would need to be reported to this office Dated 13 September2i16 Signature Assistant Coroner for Plymouth Torbay and South Devon Derriford Park, Derriford Business Park, Plymouth, PL6 5QZ Tel 01752 204636 Fax hope delay
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.