Calogero Di Blasi
15 Nov 2023 · Coroner Debbie Rookes · Avon
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of communication between specialties
“That one of the teams caring for Mr [name redacted] was completely unaware of the input from another specialty team, despite both referrals being made under the 2-week urgent referral pathway. The lack of communication between these teams meant that timely sharing of results did not occur. Even the very knowledge of the fact that a CT scan had taken place would have alerted the endoscopist to check those results, and it is likely that the second endoscopy would not have gone ahead. I understand this to”
2. reporting timeframes mismatch
“That the reporting timeframes on the 2-week urgent cancer pathway referral does not take into account timeframes for reporting investigative procedures or subsequent review by the referring clinicians.”
3. insufficient lesion recognition training
“The current training for Endoscopists for JAG certification requires the performance of 200 endoscopies. However, these tend to focus on the clinician's area of specialty and therefore there is a danger that lesion recognition will be limited and insufficient to ensure that endoscopists are able to recognise less frequently occurring lesions. With the need for an increasing number of endoscopists, action should be taken.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“That one of the teams caring for Mr [name redacted] was completely unaware of the input from another specialty team, despite both referrals being made under the 2-week urgent referral pathway.”
Later report
“Throughout the inquest, it was apparent that save for the referral by the Urology team to the Pain Service in September 2023, there was no liaison or communication between any of the specialties involved in Mr [name redacted] care, which resulted in a lack of understanding on the part of each specialty of the plans and actions of the others.”