PFD report

Mrs. Monica McCormick · Prevention of Future Deaths report

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Issued 3 Feb 2021•Manchester North

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.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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 raised4

  1. Failure to complete suspected cancer upgrade forms for malignancy-labelled pathology specimens
  2. Failure to communicate pathology reports to general practitioners at hospital discharge
    Part of recurring concern: Unreliable clinical correspondence from healthcare services to GPsPart of recurring concern: Unreliable hospital discharge processesPart of recurring concern: Unreliable pathology report tracking and follow-up
  3. Failure to consider medical records at hospital discharge
    Part of recurring concern: Failure to incorporate relevant clinical history and diagnoses into care decisions
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

    Develop and implement a standard operating procedure for New Unsuspected Cancer pathology findings.

    Stated by Oldham Care OrganisationStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
  2. Action

    Review clinical and administrative oversight of surgical outpatient cancellations and identify further improvements.

    Stated by Oldham Care OrganisationStated plannedThe respondent said that this action was planned when they made their response on 9 February 2021.
  3. Action

    Share the response at the Divisional Surgery Governance Meeting and discuss the importance of checking medical records during handover completion.

    Stated by Oldham Care OrganisationStated plannedThe respondent said that this action was planned when they made their response on 9 February 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The hospital cannot fully prevent future outpatient cancellations because COVID-19 has significantly affected already extensive waiting lists.

    Stated by Oldham Care OrganisationUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Failure to complete suspected cancer upgrade forms for malignancy-labelled pathology specimens

Wider context from the report

“Evidence was heard that the pathology sample was not followed up because despite labelling the specimen to include the word malignancy the operating clinicians did not complete an online “suspected cancer upgrade form” at the time of surgery. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Failure to communicate pathology reports to general practitioners at hospital discharge

Wider context from the report

“2. The pathology report was not communicated to her general practitioner at the time she was discharged from hospital. ”

Is this part of a recurring concern?

Yes — Unreliable clinical correspondence from healthcare services to GPs; Unreliable hospital discharge processes; Unreliable pathology report tracking and follow-up.

Open source report

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

Failure to consider medical records at hospital discharge

Wider context from the report

“1. Appropriate consideration was not given to the deceased’s medical records at the time of her discharge from hospital. ”

Is this part of a recurring concern?

Yes — Failure to incorporate relevant clinical history and diagnoses into care decisions.

Open source report

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

Failure to consider patient records when outpatient appointments are cancelled

Wider context from the report

“3. Appropriate consideration was not given to her records at the time that each outpatient appointment was cancelled ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Develop and implement a standard operating procedure for New Unsuspected Cancer pathology findings.

Verbatim wording from the response

“We can confirm that following this incident cancer services have developed a standard operating procedure for New Unsuspected Cancer pathology, so that irrespective of whether cancers are found as a consequence of treatment or investigation the patient will be added to the cancer tracking database. By adding Mrs McCormick to the database the cancellation of outpatient appointments would have been visible and appropriate resolution sought regarding the disclosure and management of the cancer. This provides the ‘safety net’ required to ensure that such a situation will not happen again in the future.”

Source location

Response from Northern Care Alliance NHS Trust
Page 2 · response
Published 9 February 2021

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 clinical and administrative oversight of surgical outpatient cancellations and identify further improvements.

Verbatim wording from the response

“cancellation of outpatient appointments would only be made taking into account the patient’s cancer diagnosis. Dr Nick Tierney has also discussed outpatient appointment cancellations with the Directorate Manager for General Surgery, who has agreed the following actions to be completed by 31st March 2021, to support the reduction of cancellation of outpatient clinic appointments:”

Source location

Response from Northern Care Alliance NHS Trust
Page 3 · response
Published 9 February 2021

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

Share the response at the Divisional Surgery Governance Meeting and discuss the importance of checking medical records during handover completion.

Verbatim wording from the response

“We apologise that the team did not check whether there had been a histopathology diagnosis at the time of discharge. We will share this PFD response at the Divisional of Surgery Governance Meeting and discuss with team members the importance of checking medical records in full when completing the Handover of Care Communication. It is important to highlight that these documents are completed throughout the patient admission to ensure a timely discharge once the patient is considered medically fit or optimised. We”

Source location

Response from Northern Care Alliance NHS Trust
Page 1 · response
Published 9 February 2021

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

Update the surgical outpatient waiting-list risk assessment, including existing controls and identified actions.

Verbatim wording from the response

“cancellation of outpatient appointments would only be made taking into account the patient’s cancer diagnosis. Dr Nick Tierney has also discussed outpatient appointment cancellations with the Directorate Manager for General Surgery, who has agreed the following actions to be completed by 31st March 2021, to support the reduction of cancellation of outpatient clinic appointments:”

Source location

Response from Northern Care Alliance NHS Trust
Page 3 · response
Published 9 February 2021

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

Add cancers identified outside diagnostic pathways to the cancer tracking database to provide oversight of treatment and appointment cancellations.

Verbatim wording from the response

“However, Dr Tierney does recognise that in the case of Mrs McCormick the delay in informing the patient of the diagnosis led to an avoidable shortening of her life. On review of the case it is recognised that the patient’s cancer was not upgraded onto the cancer pathway because the pathology specimen had arisen from Mrs McCormick’s treatment and was a new and unsuspected cancer rather than as a consequence of a diagnostic investigation such as a biopsy. Upgrade onto the cancer pathway ensures that the patient is tracked on the cancer tracking database (Somerset) so that the cancer services team can track the appropriate and timely management of cancer treatment.”

Source location

Response from Northern Care Alliance NHS Trust
Page 2 · response
Published 9 February 2021

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

Share the PFD response at the divisional surgery governance meeting and discuss the importance of fully checking medical records when completing handover communications.

Verbatim wording from the response

“We apologise that the team did not check whether there had been a histopathology diagnosis at the time of discharge. We will share this PFD response at the Divisional of Surgery Governance Meeting and discuss with team members the importance of checking medical records in full when completing the Handover of Care Communication. It is important to highlight that these documents are completed throughout the patient admission to ensure a timely discharge once the patient is considered medically fit or optimised. We”

Source location

Response from Northern Care Alliance NHS Trust
Page 1 · response
Published 9 February 2021

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 clinical and administrative oversight of surgical outpatient cancellations to identify further improvements.

Verbatim wording from the response

“cancellation of outpatient appointments would only be made taking into account the patient’s cancer diagnosis. ████████ has also discussed outpatient appointment cancellations with the Directorate Manager for General Surgery, who has agreed the following actions to be completed by 31st March 2021, to support the reduction of cancellation of outpatient clinic appointments:”

Source location

Response from Northern Care Alliance NHS Trust
Page 3 · response
Published 9 February 2021

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 a standard operating procedure ensuring cancers identified through treatment or other non-diagnostic pathways are added to the cancer tracking database.

Verbatim wording from the response

“However, ████████ does recognise that in the case of Mrs McCormick the delay in informing the patient of the diagnosis led to an avoidable shortening of her life. On review of the case it is recognised that the patient’s cancer was not upgraded onto the cancer pathway because the pathology specimen had arisen from Mrs McCormick’s treatment and was a new and unsuspected cancer rather than as a consequence of a diagnostic investigation such as a biopsy. Upgrade onto the cancer pathways ensures that the patient is tracked on the cancer tracking database (Somerset) so that the cancer services team can track the appropriate and timely management of cancer treatment.”

Source location

Response from Northern Care Alliance NHS Trust
Page 2 · response
Published 9 February 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The hospital cannot fully prevent future outpatient cancellations because COVID-19 has significantly affected already extensive waiting lists.

Verbatim wording from the response

“It is important to recognise the current challenge that the hospital faces with regard to waiting list management. The impact of COVID19 on already busy waiting lists has been significant and as an organisation we are unable to prevent the risk of outpatient cancellations fully in the future. We do however continue to take learning from incidents such as this one seriously. By introducing the use of cancer tracking for patients such as Mrs McCormick we feel assured that patients, who have a cancer diagnosis identified outside of a diagnostic pathway, will not be cancelled from outpatient waiting lists without clear recognition of the patient’s diagnosis and impact upon treatment.”

Source location

Response from Northern Care Alliance NHS Trust
Page 3 · response
Published 9 February 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Directly communicating cancer diagnoses to GPs at discharge is not standard; supported outpatient disclosure is considered best practice.

Verbatim wording from the response

“Dr Tierney has reviewed the case and confirms that the pathology report was not communicated to Mrs McCormick’s general practitioner (GP) at the time of discharge from hospital. However disclosure to GP at this time would not be standard practice. Any letter sent to the GP is also copied to the patient; this therefore would create the risk of a patient being made aware of a cancer diagnosis without appropriate support in place on receipt of the information.”

Source location

Response from Northern Care Alliance NHS Trust
Page 2 · response
Published 9 February 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The organisation cannot fully prevent future outpatient cancellations because of COVID-19 pressures and already substantial waiting lists.

Verbatim wording from the response

“It is important to recognise the current challenge that the hospital faces with regard to waiting list management. The impact of COVID19 on already busy waiting lists has been significant and as an organisation we are unable to prevent the risk of outpatient cancellations fully in the future. We do however continue to take learning from incidents such as this one seriously. By introducing the use of cancer tracking for patients such as Mrs McCormick we feel assured that patients, who have a cancer diagnosis identified outside of a diagnostic pathway, will not be cancelled from outpatient waiting lists without clear recognition of the patient’s diagnosis and impact upon treatment.”

Source location

Response from Northern Care Alliance NHS Trust
Page 3 · response
Published 9 February 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Communicating a cancer diagnosis to the GP at discharge is not standard practice because it could disclose the diagnosis without appropriate patient support.

Verbatim wording from the response

“████████ has reviewed the case and confirms that the pathology report was not communicated to Mrs McCormick’s general practitioner (GP) at the time of discharge from hospital. However disclosure to GP at this time would not be standard practice. Any letter sent to the GP is also copied to the patient; this therefore would create the risk of a patient being made aware of a cancer diagnosis without appropriate support in place on receipt of the information.”

Source location

Response from Northern Care Alliance NHS Trust
Page 2 · response
Published 9 February 2021

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.3

  1. 1

    Review clinical staff leave-management processes to ensure adequate notice under policy.

    Stated by Oldham Care OrganisationStated plannedThe respondent said that this action was planned when they made their response on 9 February 2021.
  2. 2

    Update the risk assessment for surgical outpatient waiting lists, including existing controls and any actions identified.

    Stated by Oldham Care OrganisationStated plannedThe respondent said that this action was planned when they made their response on 9 February 2021.
  3. 3

    Review clinical staff leave management to ensure adequate notice is provided under policy.

    Stated by Oldham Care OrganisationStated plannedThe respondent said that this action was planned when they made their response on 9 February 2021.

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 clinical staff leave-management processes to ensure adequate notice under policy.

Verbatim wording from the response

“cancellation of outpatient appointments would only be made taking into account the patient’s cancer diagnosis. Dr Nick Tierney has also discussed outpatient appointment cancellations with the Directorate Manager for General Surgery, who has agreed the following actions to be completed by 31st March 2021, to support the reduction of cancellation of outpatient clinic appointments:”

Source location

Response from Northern Care Alliance NHS Trust
Page 3 · response
Published 9 February 2021

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

Update the risk assessment for surgical outpatient waiting lists, including existing controls and any actions identified.

Verbatim wording from the response

“cancellation of outpatient appointments would only be made taking into account the patient’s cancer diagnosis. ████████ has also discussed outpatient appointment cancellations with the Directorate Manager for General Surgery, who has agreed the following actions to be completed by 31st March 2021, to support the reduction of cancellation of outpatient clinic appointments:”

Source location

Response from Northern Care Alliance NHS Trust
Page 3 · response
Published 9 February 2021

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 clinical staff leave management to ensure adequate notice is provided under policy.

Verbatim wording from the response

“cancellation of outpatient appointments would only be made taking into account the patient’s cancer diagnosis. ████████ has also discussed outpatient appointment cancellations with the Directorate Manager for General Surgery, who has agreed the following actions to be completed by 31st March 2021, to support the reduction of cancellation of outpatient clinic appointments:”

Source location

Response from Northern Care Alliance NHS Trust
Page 3 · response
Published 9 February 2021

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