Robert Thomas Wrinch · Prevention of Future Deaths report

On 7th April 2017, I commenced an investigation into the death of Robert Thomas Wrinch. The investigation concluded on the 21st June 2018 and the conclusion was one of Narrative: Died from the complications of an undiagnosed metastatic spinal malignancy.

The medical cause of death was; 1a) Bronchopneumonia;1b) Metastatic spinal malignancy (undifferentiated carcinoma); and II) Ischaemic heart disease

Robert Thomas Wrinch lost a significant amount of weight in 2016 and was in significant pain in his back. On 19th January 2017, it was identified that there was strong suspicion of malignancy in T10 and T11 of the vertebrae. A biopsy took place on 6th February 2017. Robert Thomas Wrinch continued to deteriorate, his pain increased and his mobility decreased. He was readmitted to Stepping Hill Hospital where he continued to deteriorate. He developed pneumonia as a consequence of his immobility. His biopsy results from 6th February 2017 were awaited at the time of his death. Post mortem examination showed that he had stage 4 undifferentiated spinal cell malignancies at T10 and T11 of his vertebrae. This was the cause of the chronic back pain and consequential loss of mobility.

1. The Inquest heard evidence that the pathology department at the Trust had no system for tracking samples. As a result, it was unclear when samples had been received and analysis had taken place. There was no documentation of conversations with other clinicians and so, it was difficult to be clear about the chronology of events. Transmission dates of the sample to another Trust were unclear. It was also difficult to know on what date the report of the pathologists findings had been issued to the treating clinician. It was unclear if these issues are specific to the pathology department of the Trust or more widespread.

2. The Trust had a system of issuing reports digitally to clinicians to speed up receipt. In addition the Inquest were told that due to preferences of clinicians paper copies were also produced and sent via internal mail to the treating clinicians. The Inquest heard that the responsible orthopaedic consultant relied on wholly on the paper system although this built in delay.

3. At the Trust, some departments such as the respiratory department had clear tracking systems to identify outstanding pathology reports. Other departments such as orthopaedics did not. As a result, clinicians could not readily identify where there was delay in receipt of information required to assess and diagnose a patient.

4. The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.

5. The Inquest heard that the delay in analysis of the sample taken was due to a backlog. The backlog was not unique to the Trust and such backlogs were prevalent across pathology departments nationally due to a local and national shortage of pathologists.