Paul Bradley

26 Jan 2024 · Coroner David Reid · Worcestershire

The coroner's concerns

1. failure to arrange in-person urology appointment for hard-of-hearing patient
“Although Mr [name redacted] had already been documented to have been hard of hearing, the urological appointment he was offered in March 2021 was by telephone, and he had not confirmed prior to that appointment that he would be willing and able to attend it. It is quite possible that he did not hear the telephone when attempts were made to contact him. It was conceded at inquest by [REDACTED], who conducted a serious incident investigation on behalf of the Trust, that it was a mistake to have tried to”
2. lack of follow-up communication after missed urology appointment
“After the urology appointment in March 2021 was missed, there is no evidence that letters seeking to rearrange it were sent either to Mr [name redacted] or to his GP. In his evidence at the inquest, [REDACTED] stated:”
3. inadequate patient tracking system for cancer treatment targets
“the urology team's system for tracking cancer patients needs to be improved..." but that "[ there is ] still some disagreement as to how this should be done”
4. lack of inter-team communication about patient care coordination
“I think the vascular team should have been keeping the urology team abreast of their contacts with Mr [name redacted]. I think maybe they lost focus of the bigger picture, i.e. that these vascular investigations were being done because of the potential renal surgery”

Stated action · mid-April 2024

“Streamline and standardise Urology MDT processes to facilitate appropriate time to discuss cases fully.”