24 Apr 2021 Alfred Jones · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Insufficient MRI scanner capacity and availability View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS England
Commission an independent review of diagnostic services to identify measures addressing diagnostic capacity and resilience.
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NHS England
Increase imaging equipment capacity in England to address diagnostic service demand.
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NHS England
Develop community diagnostic hubs to expand access to MRI, CT, ultrasound and X-ray services, including for inpatient activity.
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NHS Greater Manchester Integrated Care Board
Maintain additional outpatient MRI capacity through the mobile scanner, operating 12 hours daily, seven days a week.
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AI-generated summary
Alfred Jones · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alfred Jones was admitted to hospital after an accidental fall at home and sustained further vertebral fractures in a fall on the ward. While awaiting investigation and being medically optimised for discharge, he contracted Covid-19 in hospital and died on 7 September 2020 from bronchopneumonia in combination with Covid-19, with falls and vertebral fractures among the listed contributing conditions. The report raised concerns that shortages of MRI scanner availability and radiology staff prolonged his admission, contributing to the ward fall and Covid-19 infection.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient MRI scanner capacity and availability
Wider context from the report “1. The inquest heard that his stay in hospital was prolonged due to a shortage of availability of slots for the MRI scanner . This the inquest was told is due to a shortage of MRI scanners both in the Trust and the wider NHS . This was compounded by a shortage of radiology staff which the inquest was told formed a wider issue of a national shortage of qualified radiologists and radiographers. This led to a prolonged admission in hospital whilst awaiting tests and led to him having a fall whilst on the ward and contracting Covid-19 whilst an inpatient.
” Source location Alfred Jones · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission an independent review of diagnostic services to identify measures addressing diagnostic capacity and resilience.
Verbatim wording from the response “From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.” Source location 2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase imaging equipment capacity in England to address diagnostic service demand.
Verbatim wording from the response “From a National perspective, in supporting the ambitions of the NHS Long Term Plan, NHS England & Improvement (NHSE&I) commissioned an independent review of diagnostic services. The recently published report (October 2020), Diagnostics: Recovery and Renewal conducted by ████████ also took into account the impact of the Covid-19 pandemic. The recommendations have been accepted by NHSE&I and work has already begun to address the recommendations made, which include an increase in both imaging equipment and imaging workforce in England.” Source location 2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop community diagnostic hubs to expand access to MRI, CT, ultrasound and X-ray services, including for inpatient activity.
Verbatim wording from the response “Funding within the 2021/22 spending review has been targeted to support diagnostics via the development of community diagnostic hubs which will in turn augment access for inpatient activity in acute hospital services through the movement of elective activity to community settings. It is anticipated that MRI, CT scanning, Ultrasound and X-ray services will be the core imaging offer for these new centres and will represent new additional imaging capacity.” Source location 2021-0135-Response-from-NHS-England-and-NHS-Improvement-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain additional outpatient MRI capacity through the mobile scanner, operating 12 hours daily, seven days a week.
Verbatim wording from the response “Tameside and Glossop Integrated Care NHS FT
At the time of Mr Jones’ referral, Tameside and Glossop Integrated Care NHS Foundation Trust (T&GIC FT) was sourcing additional scanner capacity by provision of a mobile MRI scanner. This was implemented on 20th September 2020, offering additional outpatient scanning capacity for 12 hours per day, 7 days per week. The mobile MRI van is still used currently to provide additional capacity. It is also worth noting that the Trust did not reduce or delay suspected cancer patient scans due to the pandemic, and therefore, the MRI scanner was being fully utilised.” Source location 2021-0135-Response-from-GMCA-GMHSCP-Redacted
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Concerns raised 3
Failure to expedite emergency MRI scanning and document escalation attempts View source Insufficient MRI scanner capacity for urgent scans View source Failure to evaluate whether MRI capacity changes improve urgent scan times View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
East Lancashire Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
East Lancashire Hospitals NHS Trust
Operate a year-round radiology inpatient coordinator or navigator function to improve referral communication, patient flow and scan escalation.
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East Lancashire Hospitals NHS Trust
Develop a standard operating procedure defining navigator functions and referrer actions for radiology access and efficiency.
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East Lancashire Hospitals NHS Trust
Revise radiology Internal Professional Standards and monitor compliance weekly against imaging requirements.
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East Lancashire Hospitals NHS Trust
Develop and validate a traffic-light system showing radiology diagnostic waits to support escalation of urgent imaging.
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East Lancashire Hospitals NHS Trust
Operate two new MRI systems at Burnley and progress replacement and upgrading of the oldest Blackburn MRI assets.
View source
East Lancashire Hospitals NHS Trust
Roll out the radiology inpatient dashboard to wards and clinical services.
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AI-generated summary
Mr Frank Charles Medley · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to expedite emergency MRI scanning and document escalation attempts
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan . There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan ;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Source location Mr Frank Charles Medley · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient MRI scanner capacity for urgent scans
Wider context from the report “(4) The delay in obtaining the scan was partly attributed to a lack of MRI scanner capacity . At the inquest the Trust could only provide conjecture as to whether or not alterations to scan capacity had made any difference to the time taken to obtain urgent scans.
” Source location Mr Frank Charles Medley · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to evaluate whether MRI capacity changes improve urgent scan times
Wider context from the report “(4) The delay in obtaining the scan was partly attributed to a lack of MRI scanner capacity. At the inquest the Trust could only provide conjecture as to whether or not alterations to scan capacity had made any difference to the time taken to obtain urgent scans .
” Source location Mr Frank Charles Medley · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a year-round radiology inpatient coordinator or navigator function to improve referral communication, patient flow and scan escalation.
Verbatim wording from the response “Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standard operating procedure defining navigator functions and referrer actions for radiology access and efficiency.
Verbatim wording from the response “Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise radiology Internal Professional Standards and monitor compliance weekly against imaging requirements.
Verbatim wording from the response “The Internal Professional Standards (IPS) have been revised by the Radiology Directorate to support the requirements for imaging in this cohort of patients. The compliance with the standards are monitored weekly at the Radiology Performance Meeting. Phase two of the Power BI dashboard development is to include the IPS for in-patient turnaround times. We are also working on a traffic light system which will demonstrate, at a glance, the average waits for radiology diagnostics supporting the need to expedite urgent imaging. The first draft of the traffic light system is now "live" on the radiology intranet site and is being validated prior to display in a more prominent area of the Trust intranet.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and validate a traffic-light system showing radiology diagnostic waits to support escalation of urgent imaging.
Verbatim wording from the response “The Internal Professional Standards (IPS) have been revised by the Radiology Directorate to support the requirements for imaging in this cohort of patients. The compliance with the standards are monitored weekly at the Radiology Performance Meeting. Phase two of the Power BI dashboard development is to include the IPS for in-patient turnaround times. We are also working on a traffic light system which will demonstrate, at a glance, the average waits for radiology diagnostics supporting the need to expedite urgent imaging. The first draft of the traffic light system is now "live" on the radiology intranet site and is being validated prior to display in a more prominent area of the Trust intranet.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate two new MRI systems at Burnley and progress replacement and upgrading of the oldest Blackburn MRI assets.
Verbatim wording from the response “In October 2020, ELHT commissioned two new Magnetic Resonance Imaging (MRI) systems on the Burnley General Teaching Hospital site. These scanners were replacement assets identified as part of the government initiative which aimed to replace all MRI systems over 10 years old. The initial intention was to replace the Philips MRI system at Burnley and the Trust owned asset at RBH. However, due to” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out the radiology inpatient dashboard to wards and clinical services.
Verbatim wording from the response “The Radiology in patient dashboard has been developed using our business intelligence system and is currently used in key areas of the Trust. Roll out of the dashboard is progressing. The next steps are to demonstrate and share access to the dashboard at the Nursing & Midwifery Forum, Foundation Teaching and Clinical Leadership to accelerate roll out to the wards and clinical services.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.