Roy Gordon Millar · Prevention of Future Deaths report

On 29 September 2015 I commenced an investigation into the death of Roy Gordon Millar aged 62. 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. The medical cause of death was given as 1(a) Seizure and Brain Swelling; 1 (b) Glioblastoma

Mr Millar attended the A & E Department of Plymouth Hospitals NHS Trust (PHNT) on 8 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 a 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 a further scan in 3 months time was not followed up.
The Out-Patient appointment the Consultant requested in 8 weeks from the February admission was not put 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 biopsy and debulking procedure. Unfortunately Mr Millar died on the date fixed for the operation being 25 August 2015.

PHNT instigated a Root Cause Analysis following this incident, a copy of which is enclosed. ████████ the author of the Report and the Trust’s Patient Safety Lead, attended the Inquest. During the course of the hearing it emerged that the Ward Administrat or 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.

It 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 I heard was that the follow-up scan being conducted in June 2015 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.