Dear Mr 0' Donnell Re: Requletion 28 Report To Prevent Future Deaths Constance Pridmore (deceased) Thank YOU for your repart daled 12 2016, requesting & review of the Trusts procedures with regard to the assessment of X-rays, on (he basis Ihat delays in oblaining radiologists' reporls creales a foreseeable risk of future dealhs: The Trusl's Clinical Direclor for Core Clinical Services and Consultant Radiologist has reviewed our procedures and can advise &5 {ollows Introduction The number ad range of imaging invesligations performed per varies but the reporting workload is broadly predictable and University Hospitals of Morecambe NHS Foundalion Trust (UHMB) does not have sufficient reportng capacity to promply report all Ihe Images that are acquired. As Identified in your report, Ihere Is a shorlage of radiologists and this Is reflective of a nalional problem: The Royal College of Radiologlsts (RCR) has produced several snapshot surveys demonstrating the scale of the Issue_ The most recent RCR survey (February 2016) shawed that In fact; UHMB was In the upper quartile wlh no studies >1 month: In addilion, rdiology services nalionally have experienced contnual growth over the last elght years ad this brend is expected lo continue. In relation to changes in cllnical praclice, as clinical applicalions wilhin imaging technology advance, Ihe Trust will coninue lo Increase demand for the service: There is also a Increased dependence upon radiological investigations by clinicians (o support Ihe clinical decision-making process_ In 2013, Professor Sir Bruce Keogh's report recommended Ihat all inpalient Imaging investigations be compleled and reported within 24 hours However, the shartage of radiologists and Increase In workload means that this Westmorland General Hospilal Burton Road Kendal LA9 7RG CHAIR: PEARSE BUTLER Tel: 01539 732288 CHIEF EXECUTIVE: JACKIE DANIEL May day Bay

standard, inlended for achievement by 2016/17, Is widely accepted to be an ideal rather Ihan & realistic target, The Trust conlinues (o work lowards this bul il is a challenge. The lack of reporting capacity assoclated risk Is appropriately recorded on our corporale risk register, which Is reviewed at least on quarterly basis: In addition (0 priorilisation, Ihe main aclions (o address (his are around recrullment, skill mix and use of technology: Backoround Approximalely 300,000 imaging investigalions per annum are perloned at UHMB, of which 170,000 are X-rays: For (hese to be useful, Ihe images need lo be considered ad a opinian documenled. For Ihose tesls which involve radlalion, Ihls Is also & stalulory duty under the lonising Radialion (Medical Exposure) Regulations. For many sludies Ihe images will be immediately available ad will be reviewed by the clinlcian who has requested them. It is normal praclice in this trust and elsewhere (hal their oplnion Is used as Ihe basis for trealment, al least unlil such time as Ihe sludy is 'reporled' The documenlation of an opinion by someone whose maln role Is evaluating imaging is known &s 'reporling' ad is Usually carried oul by radiologist or a specially (ralned 'reporting radiographer' Reporlng end Relener Evalualion A small number of studies are considered suitable (or 'relerer evalualion' and Ihe opinion documented will be that of (he referrer; wilh an option to ask for the Ilm lo be reviewed and reported by a radiologist In these cases Ihere would be no (ommal report Issued by & radiologisL Examples of X-rays thal are considered suilable for referrer evaluation at UHMB include X-rays of Ihe (eeth revlewed by a dentist ad follow Up X-rays of healing fractures in adulls reviawed by an orthopaedic surgeon: The reason for reporler evalualion is lo make best use of reporting capacily ad also because Ihe relerer is somelimes in a belter posilion lo judge whelher the lindings are acceplable, for inslance when an X-ray relates to previous surgery and the surgeon is the best judge ol whelher ay Implanled hardware Is where Ihey intended il lo be. Referrer evalualion Is slandard practice in NHS hospilals; allhough ils scope varlas. There are many centres, for example, which apply this to all in-palient X-rays but the policy a UHMB Is considerably less extensive. The polentlal (ar Increasing (he scope of relerrer evaluation (o pravide greater reporting capacity for other studies has been considered (hrough Ihe Trusls Governance procedures but our prelered option has been (0 try lo maximise the reporting capacily avallable (0 us. We believe the scope ol relerrer evalualion wilhin the Trust (o be reasonable sale ad (here Is & standard operaling procedure t0 guide reporlers on Ihe Trust"s working practices relaling lo Image reporting: Some Trusls do not report images where a pallent has died between Ihe acquisition ad Ihe reporting of Ihe image but having sought advice on Ihis from the Medical Prolection Society, UHMB conlnues lo do s0. Working arngemenls end Pioriisallon Within UHMB Ihe Picture Archiving and Communication (PACS) system Is shared across live siles and as (ar as possible the departments prioritise an the basis ol urgency rather than geography: Work is divided into emergency cover; 'duty radiologist"' sessions ad mulli-disciplinary leam meetlng (MDT) support, wilh Ihe remaining clinical time es reporting lime. This Is subdivided into different modalilies (plaln * rays, CT, MRI, elc:) wilh the split depending on the reporters' area of expertise and (he volume of work: Inforalion about the number of studies waitng Ihe dale of the oldest studies in each modality are sent to every reporter twice a week. Wlthln each sesslon Ihe defaull position Is lo slart wilh the studies marked clinlcally urgent and then chronologically wilh the oldest study and work lowards the present; but reporters are expecled lo exercise their clinical judgement as (0 exacly which studies to report Nat all reporters can report lhe same rnge ol studies and no one person can report evary klnd of study: and and and

The waiting images are actively managed by a radiographic manager who also send work (0 oulsourcing campanles as required. Withoul addilional reporting capacily priorilsalion remalns Imporlant There are no nalional guldelines on this and allhough consideration has been glven (o constructing a Ilow diagram to assisl wilh Ihis, the complexity of what Is ultimalely a clinical decision based on number of (actors across a range o modalilles does not lend Ilsell lo such simplificalion: Urgency of imaqing Some studles are more urgent Ihan others. Sometimes Ihis is apparent Irom the moment of referral, for instance palient brought Into Ihe Emergency Department In extremis_ At other limes, however; il is not apparent Ihat Ihere are crilically important findings Ihal might immediately change the patient"s treatment unlil afler the image has been repored. When it appears Ihat a study Is urgenl then Il Is prioritised accordingly Ihe professional judgement of those in the X-ray department However, clinical risk occurs If prioritising urgent cases causes delays in reporting of routine requesis, as signilicant findings are also discovered in thls group of patients. Balancing Ihls is a further challenge. Kev Peromance Indicalors Performance Indicators are measured vla dala extraction from the Compulerised Radiology Inlormalion System (CRIS) and a perfomance dashboard is populated. Reporting backlog is monitored daily Walting Iist tracking and activity measures are reported weekly Regular job plan review productivity monltoring Is in place for all radiologists Capacity and demand work Is regularly undertaken Workforce The Dalton Review reported that lhe UK has around 48 trained radiologlsts per million population: Thls (igure has remained stalic for Ihe last five years and represents half the lolal In other EU countries. The paper considers different ways of working In terms of outsourcing; skill mix lhe use ol lechnology Io overcome the challenge and UHMB has already implemented some of these Ideas. In the UK, no appointment was made (o 41% of unfilled consullant posts advertised and the Norlh West showed a higher vacancy rate (han other regions. This rellects the experlence In UHMB where there are currenuy 5 vacancies, based on workload calculatlons from 2011, since which tlme CT and MR have both doubled In volume &nd Increased in complexily: Clearly recruilment Is central lo developing further capacity and Ihe Trust has made progress and appointed Ihree radiologists in lhe past 12 months with ongoing recruitment efforts, Including Internatlonal recruitment: Funther actions relaling (o recnuitmenLend skillmix include: Rolling programme of in-house Iraining for CTMMR radiographers Radiographer (raining plans have been identified lo fulure proof services, with funding opportunilles for training identified Addilional programmed activities and payment are on offer (o substanllve consultants to report additional work beyond their normal employed hours Westmorland General Hospital Burlon Road Kendal LA9 7RG CHAIR' PEARSE BUTLER Tel: 01539 732288 CHIEF EXECUTIVE JACKIE DANIEL will using Key and and

Support for undergraduale radiogrepher (raining from the Universlly of Cumbria and elective placements from other universities (0 allract new recruits Maximisalion ol advanced practilioner skills 8 honorary conlracts wilh external radlologists who provide ad hoc support Trust associate specialist posts avallable Rotas for 7 day and exlended day servlces agreed for radiographers in CTIMR and sonographers In Ullrasound: Locum radiologists employed when suilable and available Advice and guidance inlroduced to enable to have emall conversalions for advice and access to More complex diagnoslics ~ lo avoid unnecessary Imaging requests and slreamline the palient palhway Worklorce planning to review skll mlx and age profile of slaff Aclions relaling to technology Include; Home reporting to be explored with Ihe advent of new PACS (rom Seplember 2016, which should Improve recruitment and retention opportunities Voice recognilion technology has been rolled oul across all radiology staff, streamlining Ihe process and speeding up report lurnaround limes Qther actions and developmenlsinclude: Conlinued involvement in the 'Belter Care Together' stralegy with partner heallh care providers (0 develap clear palient palhways, oplimlsing use of imaging services, reducing unnecessary requests ad improving patient oulcomes Optimisation project to ensure relevant diagnostic tests are performed at Iha right time within specilic patient palhways and unnecessary imaging requesls are avolded hope thal you find Ihis inlonalion helpful bul if you should require ay further infomation, please do not hesllate Io contact me

Ben Gummer MP Parliamentary Under Secretary of State for Care Quality Department Richmond House of Health 79 Whitehall London POC 1034475 SWIA 2NS Mr Paul 0 'Donnell Tel: 020 7210 4850 HM Assistant Coroner 65 Duke Street Barrow-in-Furness Cumbria LAI4 IRW 12", July 2016 Lc LN Oilovcl Thank you for your letter to Secretary of State about the death of Ms Constance Pridmore_ am responding as the Minister with responsibility for patient safety at the Department of Health. [was saddened to read of the circumstances surrounding Mrs Pridmore'$ death: Please pass my condolences to her family and loved ones. Your report outlined the evidence given by several doctors at Mrs Pridmore'$ inquest and noted the following concerns, some of which are for the Morecambe Foundation Trust to address: the shortage of radiologists within the Morecambe Trust which prevented Mrs Pridmore s X-ray from reviewed by a radiologist sooner is reflective of a critical shortage of radiologists in the UK ii there are presently approximately 400 vacant consultant radiologist posts in the UK
iii. the target set in Professor Sir Bruce Keogh '$ 2013 report entitled 'NHS Services, Seven days a Week NHSI 2131 5) for urgent x-rays of inpatients to be completed (including the reporting by a radiologist) within 12 hours is far from achieved both locally by Morecambe Trust, but also nationally by all Health Trusts:
iv. This is due in part to a general increase in the use of scans and x-rays as diagnostic aids, but mainly due to the acute shortage of radiologist who are available and trained to interpret the relevant data accurately and in a timely manner; The Keogh targets whilst intended to become reality by the end of 2017 are becoming a more distant ideal than a realistically approaching target: From Bay Bay being (Paper being Bay

It is probable that current delays on both a local and national basis in obtaining in timely manner, accurate radiologist reports of x-rays and CT scans taken for diagnostic purposes. creates a foreseeable risk that further deaths may well arise as a consequence. vi: Locally, a review of your procedures with regard to the assessment of x-rays is required and nationally, a review into the implementation of the recommendations of the Keogh report is likely to be necessary. Responsibility for sta rests, as it has always done; with Trust boards. Trusts should focus on the numbers and skill mix needed to deliver quality care, patient safety and efficiency, into account local factors such as acuity and case mix: We expect all parts of the NHS to have staffing arrangements that deliver safe care making sure have the right staff; in the right place, at the right time to provide safe and effective care and t0 make the best use of their resources in doing so_ Health and Social Care Information Centre (HSCIC) statistics, show that Morecambe shows a higher percentage increase (25%) in the number of clinical radiologists than in England (20.9%) England Clinical Radiology FTE May 2010 2015 Mar 2016 Change Mar Change 2015 to Mar 2010 to Mar 2016 2016 HCHS 3,253 3,769 163 (4.3%) 680 (20.9%) Doctors 3,932 of which: Consultant (including 117 (4.3%) 529 (23.2%/) Directors of 2,285 2,697 2,814 Public Health) Source: HSCIC NHS Workforce monthly as at 31/3/16 University Hospitals of Morecambe Bay NHS Foundation Trust 2010 Mar 2015 Mar 2016 Change Change 2015 to Mar 2010 to 2016 2016 HCHS 13 14 16 (14.3%) 3 (25.0%) Doctors of which: Consultant (including 11 12 13 (8.3%) 2 (20.4%) Directors of Public Health) However; we recognise the need to continue to build the radiology workforce: ffing taking they Bay Mar May Mar May May Mar

Department of Health Heath Education England's (HEE) plans the future workforce on a national basis and is taking forward programme of action to support the Government'$ commitment to the diagnostics specialisms. Consultants in Clinical Radiology have been prioritised as part of HEE'$ investment planning process. Training posts will further increase by 32 in 2016. Work is currently in progress in respect of the radiography, radiology; non-medical endoscopy (NME), pathology, and sonography workforces: Clinical Radiology has also been one of the five specialty reviews undertaken by the planning team this year; the outcomes of which will be reported over the summer to decide intakes from 2017 onwards. This takes into account the workforce demands of the Urgent and Emergency Care Review work and will form element of planning support to the wider programme. NHS England reports that the Urgent and Emergency Care Review Sir Bruce Keogh's work is now in its implementation phase. to implementation is the development of urgent and emergency care (UEC) networks. In June 2015, NHS England published guidance for what were then emerging networks titled Role_and Establishment of Urgent and_Emergency Care_Networks and in October a total of 23 UEC networks across the four regions of NHS England were confirmed. In November; "route map was published by the NHS outlining the high-level expectations, support products, national work programmes and the expectations of UEC networks and their constituent CCGs The UEC networks are now mobilised and have responsibility to describe, develop and agree clinical pathways for urgent and emergency care in their geographies. Specifically, these networks will describe how and where patients can access the care need as conveniently as possible, the access to definitive care of all categories, severity and complexity of emergency for their defined geography and will oversee the designation of services and monitor network performance, patient outcomes and service access. that this informatiog is useful. Thank YOu for bringing the circumstances of Mrs Pridmore'$ death to our atlention. ( BEN GUMMER large key- arising from Key they hope