Sheila Stokes
9 Dec 2016 · Coroner Heidi Connor · Nottinghamshire
The coroner's concerns
1. delay in administrative follow-up of DNA appointments
“There has been delay at almost every stage of these events”
2. delay in receiving and acting on RAD alerts
“System for ensuring RAD alerts are received and acted on timeously”
3. lack of agreed protocol for custom-made grafts
“Vascular surgeons based at both KMH and NUH should consider having a clear agreed protocol for obtaining custom-made grafts”
4. delay in sending scan results to manufacturers
“A clear pathway for contacting and sending scan results to manufacturers”
5. over-reliance on few consultants
“Limited no of consultants dealing with these cases”
6. absence of named accountability for graft sign-off
“Clear timetable between first contact with manufacturer and final sign off - with responsibility of a named consultant to ensure there is no delay”
7. lack of patient communication about timelines
“Advising and updating patients on these timescales”
8. inadequate investigation of trust delay
“Adequacy of the trust's investigation of these events - in particular the morbidity and mortality meeting discussion, which was incomplete, and does not refer to delay by the trust at all”
9. misfocus of witness statements on manufacturer delay
“Nature and content of the witness statements provided to the coroner, which again refer only to delay by the manufacturer, which is clearly not the central issue in this case”
Responses
2016-0439-Response-by-Radiology-Department.pdf ↗· Sherwood Forest Hospitals NHS Foundation Trust
2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust-1.pdf ↗· Sherwood Forest Hospitals NHS Foundation Trust
Stated action · 15 July 2015
“We have now been able to determine that following referral of Mrs S to the vascular team, a letter was sent to Mrs [name redacted] (see appendix 1) on 15 July 2015; this was for an appointment on 27th July. Our Medway computer system indicates that this letter was printed on 21st July and we assume it was posted to her (see appendix 2).”