PFD report

Peter Edward SMITH · Prevention of Future Deaths report

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Issued 5 Feb 2020•Shropshire, Telford and Wrekin

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
12

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

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Concerns raised1

  1. Delays in diagnosis and treatment caused by sequential rather than concurrent coordination of tests, reports, appointments and discussions
    Part of recurring concern: Failure to provide timely urgent diagnostic investigationsPart of recurring concern: Unreliable coordination of cancer diagnosis and treatment
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.11

  1. Action

    Streamline the lung cancer diagnostic pathway through direct-to-CT referral, urgent chest X-ray reporting, and coordinated diagnostic processes.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.
  2. Action

    Implement and ratify diagnostic bundles specifying appropriate investigations for patient groups and pre-surgical risk assessment.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.
  3. Action

    Standardize pre-operative assessment to minimize clinically unnecessary tests and associated delays.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.

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

Delays in diagnosis and treatment caused by sequential rather than concurrent coordination of tests, reports, appointments and discussions

Wider context from the report

“1. There was significant delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma which contributed to his death on the 4th March 2019. 2. Time was of the essence, but tests, reports, appointments and discussions took place consecutively to the extent that by the time a final date for surgery was fixed it was no longer possible. 3. Had tests been conducted expeditiously and concurrently with predictable tests organised in advance it is likely that the surgery would have been able to take place significantly earlier than it did. ”

Is this part of a recurring concern?

Yes — Failure to provide timely urgent diagnostic investigations; Unreliable coordination of cancer diagnosis and treatment.

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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

Streamline the lung cancer diagnostic pathway through direct-to-CT referral, urgent chest X-ray reporting, and coordinated diagnostic processes.

Verbatim wording from the response

“From November 2019, the Trust has streamlined the diagnostic pathway (enclosed at Appendix 2) for patients being investigated for potential lung cancer which involved collaboration with Clinical Commissioning Group’s regarding ‘direct to CT’ pathways and to the urgent ‘hot-reporting’ of chest x-”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 1 · response
Published 8 February 2020

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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 and ratify diagnostic bundles specifying appropriate investigations for patient groups and pre-surgical risk assessment.

Verbatim wording from the response

“Improvement work has been undertaken and evaluated with regards to developing diagnostic ‘bundles’ of tests to streamline investigations and agree which investigations are appropriate for specific patient groups, recognising that each investigation involves a potential delay, but that it is important to ensure that a patient is risk assessed appropriately prior to listing for surgical intervention.”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020

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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

Standardize pre-operative assessment to minimize clinically unnecessary tests and associated delays.

Verbatim wording from the response

“• The request of additional tests can result in further delays: the Trust’s new protocol has standardised the pre-operative assessment process to try and minimise clinically unnecessary tests, recognising that each additional test builds in a potential time delay.”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020

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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

Allow PET scans to be requested before multidisciplinary discussion, requiring discussion after the PET-CT result.

Verbatim wording from the response

“• Patient’s cases do not need to be discussed at an MDT meeting in order to facilitate the requesting of a PET scan, but only following receipt of the PET CT result.”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020

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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

Update the standard operating procedure for referring suspected or confirmed lung cancer patients for surgical resection.

Verbatim wording from the response

“The Trust and the teams involved recognise the delays in this case and have reviewed their pathways and processes. From November 2019, the Trust has updated their Standard Operating Procedure (SOP) which provides advice on the referral of patients for surgical resection of proven or suspected lung cancer to prevent delays. This covers the following areas:”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 1 · response
Published 8 February 2020

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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

Continue quality improvement work towards compliance with the National Optimal Lung Cancer Pathway.

Verbatim wording from the response

“All improvements have also supported the Trust in quality improvement to work towards compliance with the National Optimal Lung Cancer Pathway which is due to come into practice by April 2020.”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020

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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

Flag concerning abnormal chest X-rays to the Lung Cancer Team daily.

Verbatim wording from the response

“• Every chest x-ray with an abnormality which is concerning for a potential lung cancer is now flagged up to the Lung Cancer Team on a daily basis. Although, in the case of Mr Smith, his initial x-ray had been reported as normal as the changes were subtle.”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020

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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

Triage CT results daily after abnormal chest X-rays raise possible lung cancer, alerting the Lung Cancer Team and responsible consultant.

Verbatim wording from the response

“• There is daily triage of CT scan results performed following receipt of an abnormal chest x-ray where the potential for lung cancer has been raised by the reporting radiologist. It has been established that had this been the case for Mr Smith, this may have reduced the timescale between radiology reporting and receipt of that report by the requesting clinician by six days. This would also trigger the Lung Cancer Team and alert the patient’s Consultant.”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020

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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 surgical clinical capacity to prevent delays in clinic appointments.

Verbatim wording from the response

“• There has been an increase in surgical clinical capacity, preventing delays for clinic appointments.”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020

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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

Maintain coordinated lung cancer working arrangements with UHNM, including weekly thoracic surgical outpatient clinics and multidisciplinary team attendance.

Verbatim wording from the response

“The Shrewsbury and Telford Hospital NHS Trust and UHNM continue to maintain close links and working closely together in the diagnosis and treatment of lung cancer patients. UHNM cardiothoracic surgeons attend SaTH weekly to operate surgical outpatient clinics and to attend weekly MDT meetings in person.”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020

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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

Agree a standard operating procedure for referrals for surgical resection of proven or suspected lung cancer.

Verbatim wording from the response

“With regard to the delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma SaTH has produced, in conjunction with and agreed by the UHNM visiting cardiothoracic surgeons, the attached Standard Operating Procedure [SOP] – “Referral for surgical resection of proven or suspected lung cancer”. SaTH has implemented the SOP and will be responding to you separately.”

Source location

2020-0022-Response-from.-UNMH
Page 2 · response
Published 8 February 2020

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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.1

  1. 1

    Discuss the revised lung cancer referral procedure at the Lung Cancer multidisciplinary team meeting.

    Stated by the Shrewsbury and Telford Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.

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

Discuss the revised lung cancer referral procedure at the Lung Cancer multidisciplinary team meeting.

Verbatim wording from the response

“• The Trust has formally discussed the SOP (referred to within section 1) at the Lung Cancer Multi-Disciplinary Team (MDT) bi-annual meeting in January 2020;”

Source location

2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Page 2 · response
Published 8 February 2020

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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