PFD report

Michael David Daft · Prevention of Future Deaths report

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Issued 24 Nov 2023•Nottinghamshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
14

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of effective communication between Multi-Disciplinary Teams from different specialisms for patients on more than one treatment pathway
    Part of recurring concern: Unreliable inter-specialty communication for complex patient care
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. Action

    Operate a monthly MDT Excellence meeting with representation from each clinical division.

    Stated by Nottingham University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 November 2023.
  2. Action

    Write overarching and individual MDT standard operating procedures to standardise MDT processes.

    Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2023.
  3. Action

    Develop and deliver standardised induction and refresher training for MDT coordinators.

    Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2023.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of effective communication between Multi-Disciplinary Teams from different specialisms for patients on more than one treatment pathway

Wider context from the report

“There is little evidence to date of effective communication between Multi-Disciplinary Teams (MDT) from different specialisms when a patient is on more than one treatment pathway. ”

Is this part of a recurring concern?

Yes — Unreliable inter-specialty communication for complex patient care.

Open source report

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 monthly MDT Excellence meeting with representation from each clinical division.

Verbatim wording from the response

“• In addition to all the above work we also have a regular MDT excellence meeting on a monthly basis as briefly mentioned. This meeting has one or more representatives present form each clinical division that feed their expertise in to the process of the MDT to help standardise the process across board.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 4 · response
Published 29 November 2023

Open published response

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

Write overarching and individual MDT standard operating procedures to standardise MDT processes.

Verbatim wording from the response

“• Agreed Standard Operating Procedures (SOPs) for individual MDT’s to be written with overarching MDT SOP to standardise the MDT process: Work is currently taking place on writing the overarching MDT SOP in conjunction with the Cancer Centre management team, Lead Cancer Clinician and other members of the MDT excellence project group. The overarching MDT SOP deadline is March 2024 and a plan is to complete 2-3 individual MDT SOPs a month. We have already started work on the individual SOPs and already completed 2-3 last month.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 3 · response
Published 29 November 2023

Open published response

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 deliver standardised induction and refresher training for MDT coordinators.

Verbatim wording from the response

“• Training and sharing: As documents and IT work are completed the Cancer Centre are supporting training and will be working on an agreed in house training programme for new starters and also to provide refresher training to in house MDT coordinators that again can be shared with Divisions to help”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 3 · response
Published 29 November 2023

Open published response

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

Distribute a Trust-wide safety briefing on risks affecting patients on multiple specialty pathways.

Verbatim wording from the response

“Safety Snippet - The Safety Team have composed a ‘safety snippet’ (a succinct safety briefing) distributed across the Trust to remind colleagues of the potential risks to patients on multiple speciality pathways, particularly when waiting times for investigations are prolonged. The importance of communicating the need for prioritisation of investigation with reference to clinical concern and potential impact of deterioration of the presenting condition has been highlighted.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 2 · response
Published 29 November 2023

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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

Implement direct Pathology Medway referrals for Cancer MDTs.

Verbatim wording from the response

“• Cancer MDTs which receive referrals directly from Pathology department to have Pathology Medway referral in place by August 2024: We have a minimum of 34 MDTs that need to be able to refer via the NUH digital system direct from pathology. We have 8 sites built and 6 in use as of January 2024. The role out of these referrals subsequently will be implemented quickly as is a standardised form.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 3 · response
Published 29 November 2023

Open published response

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

Implement Careflow referral capability for all Cancer MDTs.

Verbatim wording from the response

“• All Cancer MDTs at NUH will have MDT referral in place on Careflow by August 2024: We have a minimum of 34 MDTs that need to be able to refer via the NUH digital system. We have 19 sites that are already live and up and running, 5 sites that are in consultation / building phase and 7 areas that requiring scoping. These 7 sites are at the end of the schedule due to them having an involvement with tertiary centres or are a regional MDT so require more planning.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 3 · response
Published 29 November 2023

Open published response

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

Agree and pilot a standardised cross-Trust MDT referral process.

Verbatim wording from the response

“• Agree and pilot a standardised process for MDT referrals between Trusts by October 2024: We have already completed an initial scope and started discussions around tertiary referrals and are in the process of writing a business case for a digital system ‘Refer a patient’ for external referrals for MDT to NUH. This is fully auditable, contains a timeline of patient activity and minutes can be sent direct back to referred in a timely manner. Once a patient has been referred via this system, any activity that happens the referrer will receive either an SMS alert or email that an activity has taken place including when minutes and actions can be assigned following MDT.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 3 · response
Published 29 November 2023

Open published response

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

Streamline internal and external MDT outcome distribution, including development of web-based Infoflex recording and verification.

Verbatim wording from the response

“• MDT outcomes and distribution process: Work has already started at looking at how MDT outcomes are distributed and work will take place in line with Information Governance procedures and the MDT excellence project to streamline this process both internal and external. This is of particular relevance in this case. Currently the internal process within the Cancer Centre, is to send all outcomes to the agreed core member distribution list. If a referrer is outside of the agreed core membership they will only receive the information on the patient they have referred with via NUH email or NHS.net if external. The outcomes are also uploaded for NUH patients within NotIS, once verified, within 48 hours.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 3 · response
Published 29 November 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Provide quarterly MDT Excellence Initiative updates to the Quality and Safety Oversight Group.

    Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 November 2023.
  2. 2

    Establish an audit and ongoing review mechanism for MDT referral activity and pathway effects.

    Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 November 2023.
  3. 3

    Present the case and its learning to the Mortality and End of Life Group Governance teams.

    Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 November 2023.
  4. 4

    Review project status and determine whether MDT work should become a Trust safety priority within the 2024–2025 incident response plan.

    Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 November 2023.
  5. 5

    Hold monthly meetings with Divisional Management Teams and disseminate MDT project updates to clinical teams.

    Stated by Nottingham University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 November 2023.
  6. 6

    Establish an MDT Oversight Group to support the MDT Excellence Initiative.

    Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 November 2023.

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

Provide quarterly MDT Excellence Initiative updates to the Quality and Safety Oversight Group.

Verbatim wording from the response

“MDT Oversight Group (MDTOG) - In order to support the above project the Deputy Medical Director has requested quarterly updates be provided to the Quality and Safety Oversight Group. An MDT Oversight Group is to be established from February 2024 to support the MDT excellence work, chaired by a Deputy Medical Director and supported by Divisional Directors, Cancer Centre Clinical and Operational Leads and relevant senior clinicians. This Group will undertake a review of the project status by September 2024 to determine if this needs to be linked to the Trust’s Safety Priorities as part of the Patient Safety Incident Response Plan (PSIRP) for 2024-2025.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 4 · response
Published 29 November 2023

Open published response

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

Establish an audit and ongoing review mechanism for MDT referral activity and pathway effects.

Verbatim wording from the response

“• Reporting and query/process mechanism in place: Work will be carried out to set up an audit of MDT referral numbers within NUH (new and review), look at the amount of times a patient is referred to MDT and the effect this has on a patient pathway so we can learn from the themes and review any referrals as an ongoing process.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 3 · response
Published 29 November 2023

Open published response

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

Present the case and its learning to the Mortality and End of Life Group Governance teams.

Verbatim wording from the response

“Trust-wide learning - This case had been discussed within the Colorectal and Urology services, across two clinical divisions and will be presented to the Governance teams at the Mortality and End of Life Group (MEOLG) meeting on 1st February 2024. This was due be presented at the meeting at the beginning of January but this was rescheduled as a result of industrial action.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 2 · response
Published 29 November 2023

Open published response

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

Review project status and determine whether MDT work should become a Trust safety priority within the 2024–2025 incident response plan.

Verbatim wording from the response

“MDT Oversight Group (MDTOG) - In order to support the above project the Deputy Medical Director has requested quarterly updates be provided to the Quality and Safety Oversight Group. An MDT Oversight Group is to be established from February 2024 to support the MDT excellence work, chaired by a Deputy Medical Director and supported by Divisional Directors, Cancer Centre Clinical and Operational Leads and relevant senior clinicians. This Group will undertake a review of the project status by September 2024 to determine if this needs to be linked to the Trust’s Safety Priorities as part of the Patient Safety Incident Response Plan (PSIRP) for 2024-2025.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 4 · response
Published 29 November 2023

Open published response

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

Hold monthly meetings with Divisional Management Teams and disseminate MDT project updates to clinical teams.

Verbatim wording from the response

“• The Project Lead has monthly meetings with the Divisional Management Teams around all areas related to Cancer, including MDT so they are kept up to date of project work and can disseminate to the teams of ongoing work.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 4 · response
Published 29 November 2023

Open published response

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

Establish an MDT Oversight Group to support the MDT Excellence Initiative.

Verbatim wording from the response

“MDT Oversight Group (MDTOG) - In order to support the above project the Deputy Medical Director has requested quarterly updates be provided to the Quality and Safety Oversight Group. An MDT Oversight Group is to be established from February 2024 to support the MDT excellence work, chaired by a Deputy Medical Director and supported by Divisional Directors, Cancer Centre Clinical and Operational Leads and relevant senior clinicians. This Group will undertake a review of the project status by September 2024 to determine if this needs to be linked to the Trust’s Safety Priorities as part of the Patient Safety Incident Response Plan (PSIRP) for 2024-2025.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 4 · response
Published 29 November 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026