- Patient died after radiology failings
- Coroner raises concerns over staff shortages and discharge process
- Royal college warns consultants are “being run ragged”
An elderly patient died after clinicians missed his haemorrhage and discharged him improperly to a community hospital, prompting concerns from a coroner.
Terence Thornton, 82, died of the haemorrhage caused by a fall in September 2017. His death sparked action from Andrew Cox, assistant coroner for Plymouth, Torbay and South Devon, who warned the shortages of radiology staff “appeared to be worsening” at University Hospitals Plymouth Trust increasing the risk of similar deaths in future.
In March 2018, a Care Quality Commission report rated the trust’s diagnostic imaging service as “inadequate” and highlighted concerns over poor behaviours and attitudes from managers affecting the culture of the department.
The coroner also instructed the trust to review its process for discharging patients from the trust’s Derriford Hospital to Liskeard Community Hospital, which is run by Cornwall Partnership Foundation Trust.
In its response to the coroner, the trust said staff shortages were not a factor in Mr Thornton’s death, and a spokeswoman told HSJ the organisation was in the middle of a project aimed at improving discharges.
Giving evidence, the trust’s clinical director for radiology said they believed there was a need for up to 16 further clinicians. There were 44 radiologists working at the trust at the time.
Mr Thornton’s CT scan was initially reported as normal by UHP’s radiology department, but a subsequent review after his death revealed a “subtle, small subdural haemorrhage”.
The inquest heard evidence from an unnamed person who felt that “work pressures may have caused or contributed to the error”, according to the coroner’s Prevention of Future Death report.
A day after being admitted to Derriford Hospital Mr Thornton was discharged to Liskeard Community Hospital without an “E-discharge, a copy of his prescription chart or his prescribed medication”.
A clinician who works at Liskeard Community Hospital told the inquest that an estimated five to 10 per cent of patients “do not arrive with the correct paperwork or medication”.
According to the report, the clinician agreed with the coroner’s suggestion that “if this was allowed to continue it would inevitably result, in the future, with a patient suffering harm”.
Responding to the coroner’s report, Phil Hughes, the trust’s medical director, said the trust “compares favourably” to other similar trusts over the number of radiologists in post.
He said the trust is planning to increase the number of consultants in the radiology department by four appointments this year.
Dr Hughes said the consultant neuroradiologist checked 39 scans on the day Mr Thornton had his CT scan, which represented a “very busy day”.
He said reviewing Mr Thornton’s scan differently would have improved the chances of spotting the injury, and that “lessons have been shared with the radiology team”.
Nicola Strickland, president of the Royal College of Radiologists, told HSJ imaging consultants across the UK “are being run ragged”. She said the existing staff are picking up the estimated workload of more than 1,000 consultants missing from our workforce, which could rise to 2,000 by 2023 “unless we invest in more capacity”.
“Hospitals are mitigating radiologist shortages as best they can with locum cover and paying radiologists to report extra out-of-hours lists and external outsourcing, as well as upskilling radiographers and local networking where possible.”
Last year the CQC said that – following a national review of radiology services – radiology risks have “not been adequately” managed previously.
Asked about the trust’s discharge process, a spokeswoman for UHP said a “discharge document” is being created which will be “more helpful to patients with language they can understand” and contain “explicit instructions about next steps”.
The document will also ensure “accurate information is provided to clinicians and allied health professionals who will be involved in the patient’s ongoing care”.
The trust is awaiting IT support for required software changes associated with the project, which is expected to be implemented fully in 2020.
The spokeswoman added the trust’s action plan following last year’s CQC inspection is helping improvements to the department which is “positively changing the culture” and “helping hit targets for patients”.
Prevention of Future Death report; CQC report; Information obtained by HSJ