Hospital death leads to screening changes
SCREENING processes have been strengthened at Leicester’s Hospitals following the death of a patient who was refused tests just nine months previously.
An inquest found if the patient, Michael Halfpenny, had been treated earlier his death may have been avoided.
But failures in the system resulted in an existing aneurysm going undetected until Mr Halfpenny went to casualty with severe stomach pain.
Even then, the diagnosis did not come until three hours after arrival when he was descending into cardiac arrest. Despite rapid surgical intervention he died.
The revelations resulted in Lydia Brown, assistant coroner for Leicester and Leicestershire South, writing to the hospital trust in July this year to request action be taken to prevent future deaths.
Trust board members were provided with a report on the matter at a recent meeting.
The notice from the coroner’s office detailed the circumstances of Mr Halfpenny’s death, the cause of which was listed as multi-organ failure following emergency open repair for ruptured abdominal aortic aneurysm.
In March 2016, Mr Halfpenny had asked his GP to send him for a screening ultrasound scan for aortic aneurysm due to a strong family history.
The referral was sent to the radiology department at University Hospitals of Leicester but was rejected.
The report said: “Had the referral been received by the vascular screening team they would have offered a scan and this would have confirmed a large aneurysm and surgical repair would have been planned to take place within eight weeks.”
In the case of Mr Halfpenny the coroner’s assistant said there were concerns surrounding both the GP’s involvement as well as the hospitals.
The GP had sent the referral to radiology rather than directly to the vascular screening team, there was no follow-up on the refusal and the practice was uncertain of the existing screening programme and on what criteria to refer patients.
At the hospital there were worries over the refusal of the screening request and the fact the correct screening team were unaware of the patient.
In response to the notice, trust chief executive John Adler wrote to the coroner outlining steps taken. These included ensuring any rejection of an imaging referral has a clear statement on why, a new system for redirecting imaging referrals which get sent to the wrong team, establishment of a referral committee to provide oversight and governance and increased communication with GPs as well as new online guidance.
In the letter Mr Adler said: “I trust this response assures you that we have taken immediate and extensive actions and that we are working with internal colleagues and external partners to safeguard future users of the service.”