North Staffordshire Combined Healthcare NHS Trust, University Hospitals of North Midlands NHS Trust (P-001007)

  • North Staffordshire Combined NHS Trust 
    1.	We consider it was the responsibility of the doctor at North Staffordshire Combined NHS Trust who requested the CT scan to make Ms N aware of the findings. We think she should have been told about the evidence of a stroke being seen, even though it was an incidental finding (not related to why the scan was originally requested). We consider this caused distress to Ms N, and this has not yet been put right. We do not consider this led to any impact on Ms N’s physical health. We uphold this part of the complaint. 
    
    University Hospitals of North Midlands NHS Trust 
    2.	We do not consider there were failings in the way University Hospitals of North Midlands NHS Trust dealt with Ms N. The evidence we have seen shows the findings of the scan were properly reported and made available to the doctor that was treating Ms N. 
    
  • North Staffordshire Combined Healthcare NHS Trust
    3.	Ms N complains about North Staffordshire Combined Healthcare NHS Trust (Staffordshire Combined Trust). She says that a CT scan requested by the memory clinic on 30 October 2015 showed signs of a stroke, but that she was not told about this.  
    
    4.	Ms N says that she has been caused significant distress and she is concerned that the lack of identification and treatment may have contributed to subsequent medical conditions, particularly tinnitus and calcification of her heart valve.
    
    5.	Ms N is seeking service improvements and an apology. 
    
    
    University Hospitals of North Midlands NHS Trust
    6.	Ms N complains about University Hospitals of North Midlands NHS Trust (UHNMT). She says that a CT scan performed on 30 October 2015 (at another NHS Trust) showed signs of a stroke, but that she was not told of this until 29 June 2017.  
    
    7.	Ms N says that she has been caused significant distress and she is concerned that the lack of identification and treatment may have contributed to subsequent medical conditions, particularly tinnitus and calcification of her heart valve.
    
    8.	Ms N is seeking service improvements and an apology. 
    
  • 9.	Ms N was treated in the memory clinic at Staffordshire Combined Trust in October 2015. This was part of investigations into possible causes of occasional forgetfulness. A CT scan of the brain was ordered by the doctor in charge of her care (Dr C). This scan took place on 30 October 2015. The scan took place at UHNMT. 
    
    10.	A report on the findings of the CT scan was written by a doctor from UHNMT. The report did not identify a physical cause for Ms N’s occasional forgetfulness, but it did say there were signs of cerebellar infarction (damage to an area of the brain). This suggested Ms N had had a stroke at some point in the past. 
    
    11.	The report was shared with Dr C at Staffordshire Combined Trust. The information was not given to Ms N or to her GP as Dr C considered the findings to be incidental. 
    
    12.	In 2017 Ms N had a further scan at UHNMT. It was again noted there were signs of a previous stroke. This time the information was shared with Ms N. She was also referred to the Stroke Clinic (within UHNMT) as a precautionary measure. 
    
    13.	The Stroke Clinic told her about the incidental finding of stroke seen in 2015. Ms N said this was a significant shock to her. She complained to UHNMT that she should have been told of the stroke finding in 2015.
    
    14.	UHNMT asked Dr C for his input into the complaint before responding to Ms N. The response said: ‘If an acute finding was to be inadvertently found during this scan it would have been reported and escalated as appropriate. As your scan did not show any acute findings this was not highlighted in this way’. 
    
    15.	It went on to say: ‘you were under the care of other doctors and the scope of the clinical question was addressed in [the] memory clinic. However, if there was an incidental finding requiring urgent action this would normally be flagged with other doctors and clinicians. There was no such urgency in this case’. 
    
    16.	Ms N brought the complaint to us as she was not satisfied with this explanation.
    
  • 17.	We have considered the following information: 
    •	Ms N’s complaint to us, both in writing and in subsequent conversations and correspondence 
    •	Ms N’s medical records
    •	Complaint correspondence
    •	Correspondence with Staffordshire Combined Trust and UHNMT
    
    18.	We also obtained advice from a physician (our physician adviser) who has 15 years’ experience within the NHS, and a consultant physician (our stroke adviser) who has 30 years’ experience within the NHS, including more than ten years’ experience as a specialist stroke physician. 
    
    19.	We use related or relevant law, policy, guidance and standards to inform our thinking. This allows us to consider what should have happened. In this case we have referred to the following standards:
    •	Royal College of Radiologists (RCR) BFCR(10)5: Standards for a results acknowledgement system, April 2010
    •	National Patient Safety Agency (NPSA) Safer Practice Notice 16: Early identification of failure to act on radiological imaging reports, February 2007
    •	National Institute for the Health and Care Excellence (NICE) Clinical Knowledge Summary, Secondary Prevention following stroke and TIA, March 2017
    
  • Scan report by Staffordshire Combined Trust
    20.	We have found two guidelines that were in place at the time of the events complained about that explain what should have happened. The guidelines for radiology can be found in BFCR (10)5 from the Royal College of Radiologists (the RCR guidance). 
    
    21.	The doctor requesting the scan should have followed the guideline found in the National Patient Safety Agency Safer Practice Notice 16: Early identification of failure to act on radiological imaging reports (the NPSA guidance). 
    
    22.	The RCR guidance says it is the role of the radiologist to ensure that scan findings are reported and verified. It goes on to say: ‘It is the responsibility of the referring healthcare professional to view, act upon and record the results of imaging studies that are requested’. 
    
    23.	We have seen the RCR guidance was followed by the radiologist at UHNMT, as the finding of evidence of a historic stroke was reported to the clinician that requested the CT scan, Dr C at Staffordshire Combined Trust. 
    
    24.	The NPSA guidelines say the referring registered health professional should: ‘Inform patients of all results, positive or negative, and document that this has been done. A standard letter to patients could be an additional safety mechanism’. It goes on to say that Trusts should: ‘Define and document ‘safety net’ procedures, for example, copy reports to the GP, cancer services multidisciplinary team or other identified health professional in consultation with the referring health professional’.
    
    25.	However, the requesting doctor at Staffordshire Combined Trust did not: ‘act upon the report findings’. The NPSA guidance was not followed. Ms N was not told of the finding, and there was no safety-netting in the form of arrangements being made to convey the information to her GP. 
    
    26.	We find Staffordshire Combined Trust did not follow the guidance we have identified. Staffordshire Combined Trust should have made Ms N aware of the incidental finding of stroke in 2015. This did not happen. We consider this is a failing by Staffordshire Combined Trust.
    
    Treatment provided by UHNMT
    27.	Ms N says being told by UHNMT in 2017 she had previously suffered a stroke caused her significant distress. This was made worse when she was told this had been identified by the CT scan two years earlier, and she had not been told at that time. 
    
    28.	Ms N says that in addition to the distress this caused her, she also believes that the failure to tell her about the stroke finding means that she was not started on medication when she should have been, and that this has contributed to other medical conditions, in particular calcification of a heart valve and tinnitus.   
    
    29.	We sought further advice from our stroke adviser. Our stroke adviser agreed Staffordshire Combined Trust should have told Ms N about the signs of stroke in the CT scan. Our stroke adviser also said that starting steps to prevent secondary events (secondary preventative measures) would have been appropriate at that time. 
    
    30.	However, our stroke adviser explained it is not a prescriptive process. Either a GP or a more specialist physician could arrange and begin the secondary preventative measures. Either way, Staffordshire Combined Trust should have made the GP aware of the incidental finding and advised them to arrange secondary prevention advice and perhaps a referral to the stroke clinic. 
    
    31.	We consider it likely Ms N would have received the same precautionary treatment as suggested in NICE guidance (https://cks.nice.org.uk/stroke-and-tia#!scenario:2). This is something acknowledged by UHNMT in a letter to Ms N. 
    
    32.	In her complaint to us, Ms N said she was very concerned that the delay to starting preventative treatment put her at risk. In the response to her compliant, UHNMT said the greatest risk of reoccurrence of strokes is in the first four weeks following a stroke. It suggested that by the time the scan took place in 2015 the point of greatest risk had already passed. 
    
    33.	Our stroke adviser explained the results of the 2015 scan indicated that the stroke had likely occurred weeks if not years previously. As such the immediate risks of another stroke were less than they would be had the stroke just occurred. 
    
    34.	It appears the response references a statistical quote from the Stroke Association. In Stroke Statistics 2015 it says in the preamble: ‘the greatest risk of recurrent stroke is in the first 30 days’. However, our stroke adviser explained stroke reoccurrence is variable and dependent upon risk factors. This is why it is important for secondary prevention and review by a clinical team specifically interested in this issue, either GP, or stroke clinic, to take place. 
    
    35.	Our stroke adviser said in addition, there is a cumulative risk of stroke reoccurrence over a longer period (Risk and Cumulative Risk of Stroke Recurrence, Stroke 2011;42;1489-1494), although they did note that Ms N’s risk factors were small.
    
    36.	Our stroke adviser said it is unlikely that starting precautionary medications in 2015 would have prevented Ms N developing tinnitus. Our stroke adviser also said that while they cannot say for certain, it is unlikely that the calcification of the heart valve that Ms N has developed is linked to any delay in either reporting the findings or in beginning secondary preventative measures. 
    
    37.	We find UHNMT had no reason to make Ms N aware of the findings of the CT scan until 2017. We also consider UHNMT provided Ms N with a fair and reasonable response to her concerns. 
    
    38.	We find Staffordshire Combined Trust failed to take the correct steps following the finding of the 2015 scan. It should have made Ms N aware of the incidental finding of stroke in 2015. We consider this caused distress to Ms N when she became aware of this finding in 2017. Staffordshire Combined Trust has not yet taken any steps to acknowledge this, or to put it right. Based on this, we consider there is a failing by Staffordshire Combined Trust that has led to an injustice that is yet to be put right. 
    
    39.	We also believe Ms N would likely have started further treatment had the findings of the 2015 scan be acted upon. However, we do not consider there is evidence to say this led to any negative clinical impact on her, and therefore this has not directly caused an injustice.  
    
    40.	We do not see evidence of failings by UHNMT. Therefore, we do not uphold this part of the complaint.  
    
  • 41.	In considering our recommendations, we have referred to our Principles for Remedy. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right. 
    
    42.	We recommend that within one month of this report, Staffordshire Combined Trust should write to Ms N, acknowledging that it did not act in line with the guidance. It should also apologise for these failings, and for the distress that this caused to Ms N. 
    
    43.	Our Principles say that public organisations should seek continuous improvement and should use the lessons learnt from complaints to ensure they do not repeat maladministration or poor service. In line with this, we recommend that, within one month of the date of our final report, Staffordshire Combined Trust provides evidence to us of steps that are in place to ensure that clinicians are aware of their responsibilities to make patients aware of the findings of investigations. This should reflect the guidance we have outlined in this report.