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Northampton General Hospital Breast Service
Report of the Independent Clinical Senate Review Panel (19th July 2019)
August 2019
Glossary of abbreviations
2WW Two Week Wait
KGH Kettering General Hospital
NGH Northampton General Hospital
MDT Multi-Disciplinary Team
PHE Public Health England
MRI Magnetic Resonance Imaging
BSP Breast Screening Programme
SLA Service Level Agreement
SOP Standard Operating Procedure
WGL Wire Guided Localisation
GIRFT Getting It Right First Time
Content
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sGlossary of abbreviations............................................................................................21. Foreword by Dr Julie Attfield, Clinical Review Panel Chair..................................42. Clinical Senate Review Panel summary and key recommendations....................53. Background and advice request...........................................................................7
3.1 Description of current service model..............................................................73.2 Case for change.............................................................................................83.3 Scope and limitations of review......................................................................8
4. Methodology and governance............................................................................104.1 Details of the approach taken.......................................................................104.2 Original documents used..............................................................................11
5. Key findings from the clinical review...................................................................126. Conclusions and advice......................................................................................167. Recommendations..............................................................................................27
7.1.1 Recommendation 1................................................................................277.1.2 Recommendation 2................................................................................277.1.3 Recommendation 3................................................................................277.1.4 Recommendation 4................................................................................277.1.5 Recommendation 5................................................................................27
Appendix A: Clinical Review Panel Terms of Reference...........................................28Appendix B: Summary of documents provided by the sponsoring organisation as evidence to the panel.................................................................................................37Appendix C: Clinical review team members and their biographies, and any conflicts of interest...................................................................................................................40
Clinical Senate Support Team...............................................................................41Biographies............................................................................................................42
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1. Foreword by Dr Julie Attfield, Clinical Review Panel Chair
Clinical Senates have been established as a source of independent clinical advice
and guidance to local health and care systems, to assist them to make the best
decisions about healthcare for the populations they represent.
Clinical Senates are minimally staffed and are built on the voluntary engagement and
goodwill of local clinicians and other health and care professionals to ensure that the
wider NHS can benefit from this expertise and experience.
Since their inception, Clinical Senates have established trusted and credible
relationships with local stakeholders within their specified geographies. These
relationships have developed alongside the commissioning and regulatory
landscape as it continues to evolve, ensuring at all times continuing access to
independent and impartial clinical advice.
We would like to thank Northampton General Hospital for engaging with the East
Midlands Clinical Senate and to the staff and teams that we met on 19th July for their
professional conduct and candid conversations, coupled with the evidence provided.
This allowed the clinical review team to be able to provide independent clinical advice
and guidance to the Trust, which is the founding principle of Clinical Senates.
We would also like to thank our clinical review team for their participation and
commitment and to our panel members who were able to join us from Trusts in the
East Midlands as well as St George’s Hospital in London to ensure that any conflicts
of interest of Clinical Senate members were managed and the full potential of
independent clinical advice could be maximised.
Dr Julie Attfield
Clinical Senate Vice Chair
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2. Clinical Senate Review Panel summary and key recommendations
The clinical review team were asked to address a number of questions by
Northampton General Hospital, which were addressed in turn by the panel and are
detailed in the findings of the report. Within these findings the limitations of the
panel’s exploration are highlighted. The panel agreed with the Trust’s own
assessment that they had implemented the recommendations of the 2016 Screening
Quality Assurance Service visit (and subsequent report in 2017).
The panel considered opportunities where rationalisation or strengthening the quality
of services may be beneficial. The panel’s assessment was that the team were
delivering a routine service and that the present plastic surgery link with University
Hospitals of Leicester NHS Trust was poor, and that Northampton General Hospital
received inadequate support for the best management of complex, high risk cases
(such as patients with previous radiotherapy or ‘failed’ implant reconstructions), nor
does it allow for the provision of immediate autologous (non-implant) breast
reconstruction. The panel recommended that this should be addressed with
University Hospitals of Leicester NHS Trust or Northampton General Hospital should
liaise with a neighbouring unit such as Oxford to explore the possibility of joint clinics
to review and discuss patients which would help with decision making of patients
suitable for immediate autologous (non-implant based) reconstruction and complex,
high risk cases. Help to undertake this consideration may be found with the Cancer
Alliance.
It was highlighted that there is currently a possible duplication of services at
Northampton General Hospital (NGH) and Kettering General Hospital (KGH), and
NGH could continue to focus on collaborative working with KGH.
The panel recommended that the Trust should continue to seek to address the
significant workforce issues within the Breast Service. This related to nurses,
administration and particularly the absence of doctors below consultant grade.
Presently there is insufficient resource in terms of senior and junior medical staff in
the breast surgery team for the volume and extent of work undertaken. The risk
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associated with this is that safety issues may arise from the shortage of consultants
and the absence of dedicated juniors for escalation and reviews. It was
recommended that NGH review their process for Day Surgery patients who
unexpectedly stay overnight.
It was the panel’s assessment that the existing team is dedicated and working hard
to maintain standards. There were clear and consistent accounts given by several of
the team relating to changes put in place following recent serious incidents. These
actions were viewed to be coherent and effective.
It was recommended that a review of surgeon-specific missed excision rates or
wrong site/side should be undertaken. If any surgeon is an outlier then further
investigation should be conducted to understand the reasons for this.
The Trust has clear policies in place regarding the use of interpreters although it was
not clear if difficulties exist in the provision or timely access to this service. The
service highlighted the benefits of this information being provided on referrals so
advance booking can be put in place. It was recommended that the Trust assesses
where particular expertise around interpreter and translation services could be
captured and developed, as well as a robust quality evaluation of the interpreter
service, including patient/carer involvement to ensure that service users are fully
engaged in the evaluation process.
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3. Background and advice request The clinical review team were asked to review all aspects of the breast pathway,
(symptomatic and screening) encompassing the two week wait referral pathway,
breast screening invitation, diagnostic, and treatment phases of care. The Trust
asked that this included a review of the reconstruction pathway and the determination
of when a tertiary centre should be the route of best possible care for the patient.
The clinical review team were asked to address a number of specific questions which
are contained within the Terms of Reference and form part of the panel’s conclusions
and advice detailed in section 6 below.
The East Midlands Clinical Senate were also asked to source an external
Oncoplastic Breast Surgeon to support an internal investigation panel at
Northampton General Hospital. A consultant was sourced from Yorkshire and the
Humber Clinical Senate to ensure there were no conflicts of interest for the East
Midlands Clinical Senate.
3.1 Description of current service modelThe structure of the Breast Service is summarised in the table below:
Role Number of staff members
WTE Commentary
Breast Surgeon 4 3.6 WTE 1 surgeon is currently
on sick leave
This includes a Locum
Breast Surgeon
Consultant
Radiologist
1 1 WTE
Consultant
Radiographer
1 1 WTE
Clinical Nurse
Specialists
5 3.8
Breast Clinicians 2 1.5 0.5 WTE and 1 WTE
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There are two referral routes into the Breast Service; GP referral under 2 week wait
(Breast Pathway) or Breast Screening Pathway (invitation of women), and immediate
pedicled and implant-based breast reconstructive services are undertaken on-site.
3.2 Case for changeA number of comprehensive investigations had occurred, and serious incidents had
been investigated internally by the Review of Harm Group within Northampton
General Hospital. A Screening Quality Assurance Service visit to Northampton
Breast Screening Service in November 2016, led the Trust to request an independent
clinical review of the Breast Service to address a number of questions based on the
themes identified within the serious incidents.
3.3 Scope and limitations of reviewThe scope of the review had been agreed in advance with Northampton General
Hospital, as detailed below:
Have the breast team enacted all of the recommendations of the Screening
Quality Assurance Service 2016 visit (report published in 2017) and audited
any changes for sustained effectiveness/safety?
Is the Trust suitable to deliver complex/high risk reconstructive surgery - how
is this type of surgery determined?
How is the competency/training of the members of the MDT to deliver their
role assured?
Is there monitoring of consultant level outcomes? If not, should there be from
a national perspective?
Is the 'missed excision' rate monitored, should it be, how does this position
compare nationally?
Should 'missed excision' be treated as Serious/Moderate graded Incidents as
the patient has to return to theatre. Should these be reported to any national
database?
Is there a threshold of complex cases which the surgeons should meet in
order to continue treating specific cohorts of patients?
Is the SOP produced for 'missing wires' clinically robust?
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Does the senate consider the record keeping in the breast service to be robust
at all stages of the patients’ pathway?
Does the senate consider the patient level communication to be of a good
standard, including accessibility and timeliness?
Would the senate consider that the Trust should have any other clinical
monitoring systems/Quality Assurance system in place for patients who do not
arise via the screening programme?
Furthermore, it would be helpful for the Clinical Senate to identify any
opportunities for rationalisation of the services which may be considered as
adding quality to the breast service provided to the people of
Northamptonshire in relation to breast symptomatic and screening services
The clinical review team acknowledged at the start of the day that the panel may be
constrained by the time available at Northampton General Hospital (9.30am -
4.30pm). Every effort was made to speak to different staff groups: Senior team
consisting of the Associate Medical Director and the Deputy Director of Quality and
Governance, followed by the Programme Manager and Divisional Manager. The
clinical review team then met the following staff in the Breast Service: Consultant
Radiologist / Director of Screening, Breast Surgeons, Outpatient Clinic Staff, Breast
Care Nurses. The clinical review team then split into two groups and visited the
following areas: Day Stay Unit Theatre and PALS (Patient Advice and Liaison
Service). Lastly, the panel met with the Clinical Governance Manager.
The clinical review team agreed at the end of the day that a further panel would not
be required, as the combination of written evidence submitted, supported by
professional and clinical conversations on the day, had allowed the panel to
appropriately conclude its assessment and offer relevant conclusions and advice.
Where there were limitations to the exploration these are highlighted in the report.
The panel had not been asked to particularly comment on the serious incidents,
although as these formed the basis of the request to the East Midlands Clinical
Senate, brief feedback was provided to Northampton General Hospital and is
detailed below under the panel’s conclusions and advice.
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4. Methodology and governance 4.1 Details of the approach taken
The sponsoring organisation (Northampton General Hospital) formally engaged the
Clinical Senate on 23rd April 2019 (Matt Metcalfe, Medical Director). It was agreed
that a full day’s review would be required, and 19th July 2019 was agreed for the
clinical review panel.
Panel members and patient representatives were identified from the East Midlands
Clinical Senate Assembly membership and an approach was made to the East
Midlands Cancer Alliance Breast ECAG (Expert Clinical Advisory Group) to ensure
appropriate representation of clinical roles. Additionally, panel members were
sourced from St George’s Hospital in London to ensure the panel had sufficient
surgical expertise in Oncoplastic Breast Surgery and Plastic and Reconstructive
Surgery.
Dr Lucy Gavens and Dr Rebecca Hall, Clinical Senate Fellows, undertook a
comprehensive literature search, which focused on the specific questions the clinical
review team had been asked to address.
The clinical review panel convened at Northampton General Hospital on 19 th July to
visit the unit, meet with staff members, and consider the written evidence.
A draft report was sent to the panel members and the sponsoring organisation to
check for matters of accuracy.
The final report was submitted to the Senate Council (and ratified on 15 th August
2019).
This report was then submitted to the sponsoring organisation, Northampton General
Hospital, on 16th August 2019.
The East Midlands Clinical Senate will publish this report on its website once agreed
with Northampton General Hospital.
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4.2 Original documents usedThe full list of documents provided by the sponsoring organisation for the clinical
review panel can be found in Appendix B. The main submission included:
Comprehensive Investigation Report W-97330
Comprehensive Investigation Report Complaint 17 18 469
Serious Incident Report 2018 – 25155
Screening Quality Assurance Service visit November 2016 (report published in
2017), Public Health England
Zip file evidence (1) 03072019 (This file contained 23 individual pieces of
written evidence requested by the clinical review team and based on the
specific questions outlined in the Terms of Reference)
Zip file evidence (2) 03072019 (additional) (This file contained 6 individual
pieces of written evidence requested by the clinical review team further to the
clinical senate’s pre-panel teleconference call)
Zip file (3) 12072019 (This file contained 26 individual pieces of written
evidence requested by the clinical review team further to the clinical senate’s
pre-panel teleconference call)
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5. Key findings from the clinical review The background to the Trust approaching the Clinical Senate was provided to the
clinical review team. A number of serious incidents, summarised in the table below,
had been investigated internally by the Review of Harm Group within Northampton
General Hospital. A Screening Quality Assurance Service visit to Northampton
Breast Screening Service in November 2016, led the Trust to request an independent
clinical review of the Breast Service to address a number of questions based on the
themes identified within the serious incidents. Time was built into the agenda on 19 th
July for the serious incidents to be presented to the clinical review team and for
questions and discussion to take place.
Table 1: Summary of serious incidents presented to the clinical review team
Comprehensive
Investigation Report
(completed)
W-97330 Missed excision
Further surgery was
required which involved a
complete mastectomy and
removal of the implant
February
2019
Comprehensive
investigation Report
Complaint
(completed)
17 18 469 Confusion between a
diagnosis of Ductal
Carcinoma in Situ (DCIS)
versus breast cancer.
(The consent form
completed noted a
diagnosis of breast cancer)
October
2018
Serious Incident (SI)
Report (completed)
2018-25155 Missed wire localisation
leading to wrong site
surgery
November
2018
Initial Incident
Assessment
Form/72-hour
Report
2019/14022 Expander implant
infection/skin necrosis
Open
investigation
Serious Incident
(summary)
2018-30482 &
W-97725
Necrotising fasciitis May 2019
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CI (summary) W-104775 This investigation is still on-
going, and so the panel
were not made aware of the
full details.
Open
investigation1
The panel then heard about the relationship with a neighbouring Trust, Kettering
General Hospital (KGH), where the interactions are largely oncological, and all
radiotherapy is provided at Northampton General Hospital (NGH). The breast
services operate as separate entities (KGH and NGH) although the screening
services work closely together and there is a shared Programme Board. The Trust’s
(NGH) tertiary service is a collaboration with University Hospitals of Leicester NHS
Trust (UHL) and immediate pedicled and implant-based breast reconstructive
services are undertaken on-site at NGH. (Plastic and Reconstructive Surgeons from
UHL do not undertake surgical services on a peripheral basis at NGH).
The Breast Service workforce model was described to the panel and is summarised
in the table below.
Role Number of staff members
WTE Commentary
Breast Surgeon 4 3.6 WTE 1 surgeon is currently
on sick leave
This includes a Locum
Breast Surgeon
Consultant
Radiologist
1 1 WTE
Consultant
Radiographer
1 1 WTE
Clinical Nurse
Specialists
5 3.8
Breast Clinicians 2 1.5 0.5 WTE and 1 WTE
1 This investigation is still on-going, and so the panel were not made aware of the full details. Therefore, the panel felt unable to comment.
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The panel heard that a business case is in progress for a fourth substantive Breast
Surgeon with oncoplastic expertise and a middle grade Trust doctor. The Breast
Service does not have any doctors below consultant grade2 or Advance Nurse
Practitioners. The Breast Service has not benefited from any trainees from the Health
Education England East Midlands Programme for about 6 years. It was confirmed
that a breast care nurse is present in every assessment clinic for screening and
symptomatic patients (new diagnoses). All imaging is undertaken by NGH and not
outsourced to an outside company.
It was confirmed by the Trust that all of the 38 recommendations from the 2016
Screening Quality Assurance Service visit had been met, with 32 completed within 12
months of the report and the final 6 subsequently closed down in July 2018.
It was explained to the panel that the Breast Service has four theatre lists per week,
undertakes about 60-70 reconstructions per year (implant-based and Latissimus
Dorsi pedicled flap reconstruction) and holds twice weekly MDT (Multi-Disciplinary
Team) meetings, largely split between screening and cancers (Mondays and
Thursdays). Surgical planning for wire guided excisions3 is discussed at Monday’s
MDT meeting and these are inserted on the same day as surgery. By and large, the
surgeons know the patients they are operating on and will see their own patients if
they possibly can. Theatre staff are aware which patients should have a wire guided
excision. It was explained that clinical information and imaging is all available in
theatre and that MDT outcomes are entered live onto the Somerset Cancer Register.
The panel were informed that current practice is to handwrite the MDT outcomes and
then enter onto Somerset. This practice was described as partly historical. The panel
advised that the practice of double recording MDT outcomes should stop immediately
due to the potential for clinical discrepancy between the two. The Breast Service
2 Medical graduates enter the medical workforce as ‘junior doctors’ on a two-year work-based training programme known as the ‘foundation programme’ often referred to as FY1 or FY2. Specialty training for doctors can take up to eight years depending on the area and during this time they are still considered ‘junior doctors’ and work under the supervision of a more senior doctor, usually a consultant. Doctors in specialty training are often referred to as specialty trainees (ST) or speciality registrars StR, and sometimes the year of training is included in this title, for example, ST4 would mean a junior doctor that is in their fourth year of specialty training (Doctors’ titles: explained, British Medical Association).3 Wire guided excision biopsy means putting a thin wire into an abnormal area of breast tissue. This pinpoints an area to be removed with surgery (Cancer Research UK).
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agreed that they will be phasing out handwritten notes although the panel’s advice
was that this practice is simply stopped straightaway.
It was confirmed that it is Trust policy that if a wire is not present then a surgeon
should not continue with the planned surgery.
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6. Conclusions and adviceA comprehensive literature search of relevant national guidelines and evidence was
undertaken by Dr Lucy Gavens and Dr Rebecca Hall, Clinical Senate Fellows, in
advance of the clinical review panel. Three main approaches to collate relevant
information were undertaken:
Literature search in June 2019 to identify relevant evidence and clinical
guidelines
Review of evidence shared by Northampton General Hospital (e.g. material
from the 2016 audit)
Conversations with colleagues to understand what data is available nationally
Their findings have been incorporated into the panel’s conclusions and advice
detailed in this section.
As the clinical review team had been asked to address a number of questions by
Northampton General Hospital, the panel in summarising its conclusions and advice,
responded to each question in turn, as laid out here.
Have the breast team enacted all of the recommendations of the 2017 Screening
Quality Assurance Service visit report and audited any changes for sustained
effectiveness/safety?
The panel understood that following the Screening Quality Assurance Service visit in
November 2016 a detailed action plan was developed. The PHE Screening Quality
Assurance Service (SQAS) actively followed up the actions and after 1 year:
32 actions had been satisfactorily closed
6 recommendations were outstanding which related to:
The incident management process
Staffing structure for breast imaging
Availability of clinical nurse specialists for assessment clinics
A plan for double reporting high risk screening MRIs
Availability of clinical nurse specialists for all women receiving a diagnosis
of cancer
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Process for recording patient outcomes during MDT should be reviewed to
ensure that these are recorded accurately and that there is only a single
validated record of the discussion
SQAS handed over to NHS England Central Midlands commissioning team for
oversight to resolve the remaining recommendations in April 2018
From an email (between NHS England and Northampton General Hospital)
provided as evidence to the panel, it appeared these were resolved in July
2018
Evidence of completion of the outstanding recommendations was corroborated by
the clinical review team with Public Health England for the purposes of providing
comprehensive assurance. It has also been confirmed by Public Health England that
at their recent SQAS prioritisation day in May 2019, they had no significant concerns
with the NGH breast screening service and as such they are intending to visit again
in early 2021.
The breast team had also confirmed to the panel that it had been formally recognised
by the commissioners that the outstanding actions had now been closed. The panel
were satisfied, having also sought verification externally, that this was now resolved
and that the Trust’s own internal assurance process should be sufficient evidence of
compliance.
Is the Trust suitable to deliver complex/high risk reconstructive surgery – how is this
type of surgery determined?
The panel were of the opinion that the breast team is delivering a routine service and
that complex is not the right terminology to use to describe the existing service. The
panel felt that complex/high risk created two separate questions. Complex surgery
was not felt to be delivered at NGH as the type of surgery undertaken by the Breast
Service at Northampton General Hospital was considered to be routine procedures
only. This presents potential access issues in terms of patient options and access to
autologous reconstructions. There may be a question of performing routine surgery
on high risk patients, which was felt to be different. The panel felt this to be a case for
compromise between the risk of surgery and patient wishes to have reconstruction.
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It was felt that this was demonstrated in one of the serious incidents where the strong
patient wishes were taken into account with appropriate informed consent processes
in place to ensure understanding of the risks. Consent for implant/expander
reconstruction should include infection/loss of implant/expander, which is a
recognised but uncommon risk of the procedure. With prior radiotherapy, a patient
would be at higher risk for all types of breast surgery and reconstruction. It is not
possible to mitigate this risk other than refusing reconstruction. However, no
guideline states that patients who have had radiotherapy should not be offered
reconstruction with patient choice being an important factor to consider.
The panel were concerned that currently, the plastic surgery link with Leicester
appears to be poor and does not provide adequate support for the best management
of complex cases, nor does it allow for the provision of immediate autologous (non-
implant) breast reconstruction. This needs to be addressed, either with Leicester or
with one of the other neighboring plastic surgery units. Plastic surgery support with
joint clinics to review and discuss such patients will support decision making in
complex, high risk cases, and is in keeping with the standard of care in the UK.
Additionally, based on the written evidence submission to the clinical review team, it
was confirmed that Northampton General Hospital meet the key clinical requirements
for an Oncoplastic (OP) Service, with regards to the threshold of reconstruction
cases. The unit undertakes about 60-70 reconstructions per year (implant and
pedicled flap reconstruction).
Oncoplastic Breast Reconstruction – Guidelines for Best Practice (2012)The OPU is defined as a core component of a breast unit typically providing a breast
service for a local population of 250,000 or more. The workload and case mix of the
OPU should be sufficiently varied to offer patients a full range of choices, maintain
competence and ensure Continuing Professional Development (CPD).
OPUs should perform 25 or more major OP procedures per year which should
include the following case mix:
Immediate and delayed techniques
Implants and expanders
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Primary procedures - subpectoral/LD reconstruction, oncoplastic breast
conserving surgery (OPBCS), immediate bilateral reconstruction following risk-
reducing mastectomy
Secondary procedures - symmetrising surgery, nipple reconstruction and
pigmentation (with adequate training, and a recall register), elective implant or
expander exchange, injection port removal
Tertiary procedures - implant or expander exchange for complications,
capsulotomy and capsulectomy, correction of poor cosmetic outcome,
lipomodelling for conditions endorsed by the Lipomodelling Guidelines for
Breast Surgery
How is the competency/training of the members of the MDT to deliver their role
assured?
The panel concluded that it had no issues regarding competency or training of staff
based on the written evidence that had been supplied to and examined by the clinical
review team.
Surgical guidelines for the management of breast cancer (2009) Surgical treatment of patients with breast cancer must be carried out by
surgeons with a special interest and training in breast disease.
Each surgeon involved in the NHS BSP should maintain a surgical caseload of
at least 10 screen-detected cancers per year, averaged over a three-year
period.
Surgeons with low caseloads should be able to demonstrate an annual
surgical workload of at least 30 treated breast cancers.
Breast surgeons should work in breast teams, which have the necessary
expertise and facilities for a multidisciplinary approach.
The panel did raise concerns that the Breast Service is significantly under resourced
below consultant grade and that this creates a degree of risk. The panel were
concerned that safety issues may have arisen as a consequence of the Breast
Service being significantly medically understaffed. Moreover, it was not clear whether
there is a process in place for the Breast Surgery Consultant to be informed if a Day
Surgery patient has unexpectedly stayed overnight. The Trust should ensure that
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such a process exists and that the senior breast surgery team (i.e. the consultants)
are aware of all in-patients in the hospital at any given time. There should be a daily
medical review of all inpatients by a member of the breast surgery team. At present
there appears to be insufficient resource to allow this to happen in terms of senior
and junior medical staff in the breast surgery team. It was clear to the panel that for
the number of cancer cases and overall breast referrals seen per year the
department is currently under-staffed. This should be viewed by the Trust as a risk
and addressed as a matter of urgency.
The panel felt that the service and its needs may not be well understood by
managers and senior clinicians beyond the service itself. The panel observed that
some staff felt that concerns have been raised previously about resources and
practice that were not adequately responded to in a timely way. An example related
to what seemed to be previously elongated or unsuccessful business case
processes.
Is there monitoring of consultant level outcomes? If not, should there be from a
national perspective?
The panel confirmed that there is no national monitoring of consultant level outcomes
for breast cancer surgery and this was verified by the Senior Analytical Lead at NHS
England and NHS Improvement - Midlands. The panel were satisfied that the team
had in place appropriate internal audit and were provided with evidence that the
quarterly review of data undertaken by the team supported learning and influenced
practice. It was clear that the capacity within the team and lack of juniors meant that
opportunities for further audit were missed due to lack of capacity to pull, collate, and
interpret data.
Is the ‘missed excision’ rate monitored, should it be, how does this position compare
nationally?
The panel confirmed that missed excision rates are not monitored nationally.
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Should ‘missed excision’ be treated as Serious/Moderate graded Incidents as the
patient has to return to theatre? Should these be reported to any national database?
The panel believed incidents should be reviewed on a case by case basis to
determine the severity. There is not a national database however the panel
understood that unexpected returns to theatre are recorded by the Trust. Missed
excisions are rare but do occur. It was noted (in the related comprehensive
investigation case) the patient was obese with a very high BMI, which makes a
missed excision more likely. However, it was also felt that with a clear understanding
by the surgeon of where the tumour lay and careful technique a 20mm tumour should
probably not have been missed in the original skin sparing mastectomy excision. A
review of surgeon-specific missed excision rates should be undertaken (this was not
available to the panel). If any surgeon is an outlier then further investigation should
be conducted to understand the reasons for this. The panel did query the level of
specialist expertise in the grading of incidents, or their level of clinical consideration.
(The Trust confirmed to the panel that in the related comprehensive investigation an
external oncoplastic breast surgeon had been sourced).
Is there a threshold of complex cases which the surgeons should meet in order to
continue treating specific cohorts of patients?
The panel felt this question had previously been addressed and referred to the
guidelines highlighted above. It was reiterated that the word complex should be
dropped in this context for the reasons described earlier in this report.
Is the SOP produced for ‘missing wires’ clinically robust?
The panel confirmed that the SOP is clinically robust but from at least one incident it
was evident that at least one member of the team did not follow the procedure. The
panel had also observed that record keeping systems are readily available for all staff
(e.g. in theatre) when needed.
Additionally, the clinical review team confirmed that there are no specific national
guidelines for ‘missing wires’. Guidelines cover best practice for pre-operative
location of non-palpable lesions.
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‘Localization techniques for guided surgical excision of non-palpable breast
lesions (Review)’ Chan et al. Cochrane Database of Systematic Reviews
2015, Issue 12
Results from this Cochrane review support the continued use of Wire
Guided Localisation (WGL) as a safe and tested technique
Update on Preoperative Breast Localization. Hayes, M. Radiological Clinics of
North America. 55 (2017) 591–603
Specifically recommends good communication between the radiologist
and surgeon both pre and post wire localisation.
This communication is suggested as direct communication between the
professionals, annotation of images and marking the patient.
Shortest time between WGL and the patient being taken to theatre as
possible to minimise the chance of wire migration.
Standard WL procedure specimen radiography provides documentation
of excision of the entire wire. If the entire wire is not verified as
expected, then the radiologist must notify the surgeon to search for and
retrieve the missing wire fragments.
Does the senate consider record keeping in the Breast Service to be robust at all
stages of the patients’ pathway?
The panel recognised that there may not be sufficient capacity (this observation
covered both administration and clinical capacity in terms of assistance with data
entry and clinical audit) within the Breast Service for data entry and audit and that
assistance may be required. The Clinical Senate suggest that the organisation would
need to audit their documentation at five key stages in the patient journey:
Point of referral Source of referral (GP/NHS BSP/other MDT/ Consultant)
Date of referral
Contact details
Date of first being seen by breast specialist
Reason for referral (documentation of the 2ww criteria)
Number of referrals subsequently found to have cancer should be recorded
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Mechanism for tracking patients who have not responded to the appointment
invite
Initial consultation Documentation of person undertaking initial consultation
Family history taken and consideration of referral to the local genetics clinic
If needs genetics referral, has this been made
Has triple-assessment been achieved? If not achieved, it should be
documented as to why not
Has this assessment all occurred at the same visit? If not, document as to why
not
Follow-up Appointment Results of initial assessment communicated to the patient in 5 working days?
If triple-assessment is negative, is there documentation of the patient being
advised to seek medical advice if further signs or symptoms develop?
Non-operative diagnosis for invasive cancers achieved with a minimum of
90% of cases and target of 95%
Non-operative diagnosis for screen detected cases achieved with a minimum
standard of 85% and target of 90%
Has the patient been offered a date for surgery if needed at this appointment?
Pre-operative work-up Documentation for reasons regarding pre-treatment screening at MDT
Time taken to achieve this screening should be recorded
MDT should record all key dates with regards to treatment and diagnosis
Method of localisation of the lesion agreed and documented at the MDT
Operative documentation Surgeon and assistants undertaking the procedure
Any intraoperative imaging/sections taken and communication with the
supporting radiologist/pathologist
Any complications during the procedure documented
Surgical margins achieved
Page | 23
Royal College of Pathologists Breast Cancer Minimum Dataset Report
(Reporting Proformas for Breast Cancer Surgical Resections. May 2016)
Does the senate consider the patient level communication to be of a good standard,
including accessibility and timeliness?
The panel did not conduct a thorough review of clinical documentation given the time
available and the following comments are made in this context.
The panel noted very positive aspects of communication with a breast care nurse
present in every assessment clinic for screening and symptomatic patients (new
diagnoses). However, the panel understood that there are significant language needs
within the local population and the panel perceived issues with respect to access to
translation services in some cases presented to the clinical review team.
An issue was raised with the panel regarding accurate completion of the breast
suspected cancer 2WW referral form. This form was subsequently requested by the
clinical review team and there is a language needs section on the referral form that
needs to be completed by primary care to ensure that appropriate interpreter
services can be arranged in preparation for first appointments. The clinical review
team were not able to corroborate this as the panel did not review any referral forms
completed by primary care, although it will be important for NGH to work with Nene
and Corby CCGs to ensure feedback is provided to primary care where this is not
completed and results in poor patient experience. It was recommended that the Trust
assesses where expertise around interpreter and translation services could be
captured and developed, as well as undertaking a robust quality evaluation of the
interpreter service. It appeared to the panel that there was a lack of service user
evidence about how effective the interpreter service is, and a qualitative evaluation
would seem to be beneficial.
The Trust has clear policies in place regarding the use of interpreters. It was not clear
to the panel if difficulties exist in the provision of or timely access to this service.
For all points of communication with the patient it should be conducted in a language
the patient comprehends. If English is not the patient’s first language, a professional
Page | 24
interpreter should be arranged. Family members, in particular children, should not be
used as translators. The Trust’s guideline is compliant in this regard.
The following information is provided for the Trust to consider further to the clinical
review panel on 19th July:
Point of referral Has the patient received any documentation about why the doctor has referred
urgently to the breast clinic?
Regardless of referral route, has the patient received any literature describing
what to expect at the clinic appointment?
Initial appointment and Follow up appointment Has the patient been seen by a specialist who is a part of the breast MDT?
Was a breast cancer specialist nurse present in the appointment?
Clear documentation of risks and benefits to any procedure undertaken
Consent discussed and signed, and a copy given to the patient
Post-operativelyA written summary of treatment is given to the patient and a copy to the GP
including:
Designated named healthcare professional
Dates for review of any adjuvant therapy
Wound care advice
Dates of surveillance mammography
Signs and symptoms to look for and seek advice on
Contact details for immediate referral back to specialist care
Contact details for support organisations
Would the senate consider that the Trust should have any other clinical monitoring
systems/Quality Assurance system in place for patients who do not arise via the
screening programme?
The Breast Service alluded to support from GIRFT when it met with the clinical
senate review team. The Trust may wish to consider further support from the NHS
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England and NHS Improvement Quality Surveillance Team (QST) Peer Review
Process.
Furthermore, it would be helpful for the Clinical Senate to identify any opportunities
for rationalisation of the services which may be considered as adding quality to the
breast service provided to the people of Northamptonshire in relation to Breast
symptomatic and screening services
The panel noted duplication of services with KGH as the breast services clinics and
MDTs are separate entities. The opportunity to collaborate with neighbouring plastic
surgery units was recommended strongly by the panel.
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7. Recommendations 7.1.1 Recommendation 1The panel recommends that the Trust explores the possibility of a formal SLA with
their surrounding plastic surgery units (either Oxford or Stoke Mandeville Hospital)
and/or that the current SLA with Leicester is significantly strengthened.
7.1.2 Recommendation 2The panel recommends that the Trust should address the significant workforce
issues within the Breast Service and particularly the absence of doctors below
consultant grade, with the possibility of exploring the use of physician associates.
7.1.3 Recommendation 3The panel recommends that a process is put in place for the Breast Surgery
Consultant to be informed if a Day Surgery patient has unexpectedly stayed
overnight. The Trust should ensure that the senior breast surgery team (i.e. the
consultants) are aware of all inpatients in the hospital at any given time. There should
be a daily medical review of all inpatients by a member of the breast surgery team.
7.1.4 Recommendation 4A review of surgeon-specific missed excision rates or wrong site/side should be
undertaken. If any surgeon is an outlier then further investigation should be
conducted to understand the reasons for this.
7.1.5 Recommendation 5The Trust should assess where particular expertise around interpreter and translation
services could be captured and developed, as well as a robust quality evaluation of
the interpreter service, including patient/carer involvement to ensure that service
users are fully engaged in the evaluation process.
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Appendix A: Clinical Review Panel Terms of Reference
CLINICAL REVIEW TERMS OF REFERENCE
Title: Northampton General Hospital Breast Services
Sponsoring Organisation: Northampton General Hospital
Clinical Senate: East Midlands
NHS England regional or area team: Midlands
Terms of reference agreed by:
Name: E Orrock/J Attfield on behalf of clinical senate and
Name: Matt Metcalfe on behalf of sponsoring organisation
Date: 21st May 2019
Clinical review team members
Chair: Dr Julie Attfield, Executive Director Nursing, Nottinghamshire Healthcare NHS
Trust and Clinical Senate Vice-Chair
Panel members:
Name Role Organisation
Ben Anderson Deputy Director for
Healthcare Public Health
Public Health England
East Midlands
Miss Nadine Betambeau Consultant Oncoplastic
Breast Surgeon
St George’s Hospital,
London
Dr Ann Boyle Associate Postgraduate
Dean
Health Education England
East Midlands
Charles Carroll Cancer Centre Manager United Lincolnshire
Hospitals NHS Trust
Susan Edge Patient Representative East Midlands Clinical
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Senate
Dr Lucy Gavens
(will dial in to present the
literature review as cannot
attend in person)
Specialty Registrar in
Public Health
University Hospitals of
Derby and Burton
Clinical Senate Fellow
Dr Rebecca Hall GP Charnwood Community
Medical Group
Clinical Senate Fellow
Amanjot Karuppiah Consultant Radiologist Sherwood Forest
Hospitals Trust
Mr Jonathan Lohn Consultant Plastic and
Reconstructive Surgeon
St George’s Hospital,
London
Jackie O’Sullivan Breast CNS Nottingham University
Hospitals NHS Trust
Claire Porter Lead Nurse for Burns and
Plastics
Leicester Royal Infirmary
Mandy Rudczenko Patient Representative East Midlands Clinical
Senate
Mr Martin Vesely Consultant Plastic
Surgeon
St George’s Hospital,
London
Aims and objectives of the clinical review
The clinical review team are being asked to address the following questions, which
are based on the themes identified within four incidents (over a 12-month period) and
the triangulation of other data:
Have the breast team enacted all of the recommendations of the Screening
Quality Assurance Service 2016 visit (report published in 2017) and audited
any changes for sustained effectiveness/safety?
Is the Trust suitable to deliver complex/high risk reconstructive surgery - how
is this type of surgery determined?
How is the competency/training of the members of the MDT to deliver their
role assured?
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Is there monitoring of consultant level outcomes? If not, should there be from
a national perspective?
Is the 'missed excision' rate monitored, should it be, how does this position
compare nationally?
Should 'missed excision' be treated as Serious/Moderate graded Incidents as
the patient has to return to theatre. Should these be reported to any national
database?
Is there a threshold of complex cases which the surgeons should meet in
order to continue treating specific cohorts of patients?
Is the SOP produced for 'missing wires' clinically robust?
Does the senate consider the record keeping in the breast service to be robust
at all stages of the patients’ pathway?
Does the senate consider the patient level communication to be of a good
standard, including accessibility and timeliness?
Would the senate consider that the Trust should have any other clinical
monitoring systems/Quality Assurance system in place for patients who do not
arise via the screening programme?
Furthermore, it would be helpful for the Clinical Senate to identify any
opportunities for rationalisation of the services which may be considered as
adding quality to the breast service provided to the people of
Northamptonshire in relation to Breast symptomatic and screening services
Scope of the review
The Clinical Senate are asked to review all aspects of the Breast pathway,
symptomatic and screening: The patients' pathway from 2ww, screening invitation
through to the diagnostic and treatment phases of care. The Trust asks that this
includes a review of the reconstruction pathway and the determination of when a
tertiary centre should be the route of best possible care for the patient.
When reviewing the case for change and options appraisal the Clinical Review Panel
should consider (but is not limited to) the following questions:
Will these proposals deliver real benefits to patients (access/clinical
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outcomes/quality4)? For example, do the proposals reflect:
o The rights and pledges in the NHS Constitution?
o The goals of the NHS Outcomes Framework?
o Up to date clinical guidelines and national and international best
practice e.g. Royal College reports?
Is there evidence that the proposals will improve the quality, safety and
sustainability of care? For example:
o Do the proposals align with local joint strategic needs assessments,
commissioning plans and joint health and wellbeing strategies?
o Does the options appraisal consider a networked approach -
cooperation and collaboration with other sites and/or organisations?
o Is there a clinical risk analysis of the proposals, and is there a plan to
mitigate identified risks?
Do the proposals meet the current and future healthcare needs of their
patients?
Do the proposals demonstrate good alignment with the development of other
health and care services?
Do the proposals support better integration of services?
Do the proposals consider issues of patient access and transport? Is a
potential increase in travel times for patients outweighed by the clinical
benefits?
Will the proposals help to reduce health inequalities?
Do the proposals consider the workforce requirements and transformation required to deliver this new model?
The Clinical Review Panel should assess the strength of the evidence base of the
case for change and proposed models. Where the evidence base is weak then 4 Quality (safety, clinical effectiveness and patient experience)
Page | 31
clinical consensus, using a voting system if required, will be used to reach
agreement. The Clinical Senate Review should indicate whether recommendations
are based on high quality clinical evidence e.g. meta-analysis of randomised
controlled clinical trials or clinical consensus e.g. Royal College guidance, expert
opinion.
Timeline
The various options pertaining to this review have been discussed with the Trust. The
clinical review team will need to determine if a further date is required following the
site visit (either face-to-face or virtual). The Trust acknowledges that this could be
into September due to the summer holidays and annual leave for some of the panel
members. If a follow up date for a clinical review panel is required, this will be
incorporated into this TOR.
Dr Lucy Gavens and Dr Rebecca Hall, Clinical Senate Fellows, will undertake a
literature review which will support the Key Lines of Enquiry for the site visit.
Reporting arrangements
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Sponsoring organisation
engaged Clinical Senate
23.4.19
Submission of supporting evidence to
Clinical Senate23.4.19Further
evidence may be requested
by 5.7.19
Clinical review panel (site
visit)19.7.19
Draft report to the sponsoring
organisation for factual accuracy
2.8.19
Sponsoring organisation
to respond by9.8.19
Senate Council formal
endorsement15.8.19
Submission of final report
16.8.19
Publication and
dissemination of the
information byAs agreed with
the Trust
The clinical review team will report to the clinical senate council which will agree the
report and be accountable for the advice contained in the final report.
Clinical Senate Council will report to the sponsoring organisation and this clinical
advice will be considered as part of the NHS England assurance process for service
change proposals (if appropriate).
Methodology
The sponsoring organisation has agreed to collate and provide the following
supporting evidence:
Case for change and a summary of the current position and proposed
alternative service/care model
Impact of withdrawing/reconfiguring services, including risk register and
mitigations
How proposals reflect clinical guidelines and best practice, the goals of the
NHS Outcomes Framework and Constitution
Alignment with local authority joint strategic needs assessments and a
narrative around health inequalities and demographics
Evidence of alignment with STP plans
Evidence of how any proposals meet future healthcare needs, including
activity modelling, pathways, and patient flows
Demonstrate how patient access and transport will be addressed
Consideration to a networked approach
Education and training requirements
Implications on workforce (to be able to demonstrate alignment to new ways of
working, and to describe how the future workforce will look to support any new
models of care/reconfiguration proposed)
Implications for the workforce (to describe how the workforce will be engaged,
supported and motivated to work in new ways and in new places that support
any new models of care/reconfiguration proposed)
Implications for the clinical support services and those staff (e.g. clinical
engineering, radiology, pharmacy)
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SHAPE (Strategic Health Asset Planning and Evaluation) Place Atlas, which
helps organisations to consider the evaluation of the impact of service
configuration on proposals and assess the optimum location of services
Report
A draft clinical senate report will be circulated within 10 working days of the final
meeting - to team members for comments, to the sponsoring organisation for fact
checking.
Comments/ corrections must be received within a further 5 working days.
The final report will be submitted to the sponsoring organisation by 16 th August 2019.
Communication and media handling
The clinical senate will publish the final report on its website once it has been agreed
with the sponsoring organisation. The sponsoring organisation is responsible for
responding to media interest once in the public domain.
Disclosure under the Freedom of Information Act 2000
The East Midlands Clinical Senate is hosted by NHS England and operates under its
policies, procedures and legislative framework as a public authority. All the written
material held by the clinical senate, including any correspondence you send to us,
may be considered for release following a request to us under the Freedom of
Information Act 2000 unless the information is exempt.
Resources
The senate office will provide administrative support to the review team, including
setting up the meetings, taking minutes and other duties as appropriate.
The clinical review team will request any additional resources, including the
commissioning of any further work, from the sponsoring organisation.
Accountability and Governance
The clinical review team is part of the East Midlands Clinical Senate’s accountability
and governance structure.
Page | 34
The East Midlands Clinical Senate is a non-statutory advisory body and will submit
the report to the sponsoring organisation.
The sponsoring organisation remains accountable for decision making but the review
report may wish to draw attention to any risks that the sponsoring organisation may
wish to fully consider and address before progressing with their proposals.
Functions, responsibilities and roles
The sponsoring organisation will
provide the clinical review panel with all relevant background and current
information, identifying relevant best practice and guidance. Background
information may include, among other things, relevant data and activity,
internal and external reviews and audits, impact assessments, relevant
workforce information and projection, evidence of alignment with national,
regional and local strategies and guidance (e.g. NHS Constitution and
Outcomes Framework, Joint Strategic Needs Assessments, CCG two- and
five-year plans and commissioning intentions)
respond within the agreed timescale to the draft report on matters of factual
inaccuracy
undertake not to attempt to unduly influence any members of the clinical
review team during the review
submit the final report to NHS England for inclusion in its formal service
change assurance process (if appropriate)
arrange and bear the cost of suitable accommodation (as advised by the
senate office) for the panel and any panel members
Clinical senate council and the sponsoring organisation will
agree the terms of reference for the clinical review, including scope, timelines,
methodology and reporting arrangements
Clinical senate council will
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appoint a clinical review team; this may be formed by members of the senate,
external experts, or others with relevant expertise. It will appoint a chair or
lead member
endorse the terms of reference, timetable and methodology for the review
endorse the review recommendations and final report
provide suitable support to the clinical review team
Clinical review team will
undertake its review in line with the methodology agreed in the terms of
reference
follow the report template and provide the sponsoring organisation with a draft
report to check for factual inaccuracies
submit the draft report to clinical senate council for comments and will
consider any such comments and incorporate relevant amendments to the
report. The team will subsequently submit final draft of the report to the
Clinical Senate Council
keep accurate notes of meetings
Clinical review team members will undertake to
Commit fully to the review and attend all briefings, meetings, interviews,
panels etc. that are part of the review (as defined in methodology)
contribute fully to the process and review report
ensure that the report accurately represents the consensus of opinion of the
clinical review team
comply with a confidentiality agreement and not discuss the scope of the
review or the content of the draft or final report with anyone not immediately
involved in it. Additionally, they will declare, to the chair or lead member of the
clinical review team and the clinical senate manager, any conflict of interest
prior to the start of the review and /or which may materialise during the review
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Appendix B: Summary of documents provided by the sponsoring organisation as evidence to the panel
The following documents were provided as evidence to the clinical review panel:
Comprehensive Investigation Report W-97330
Comprehensive Investigation Report Complaint 17 18 469
Serious Incident Report 2018 – 25155
Screening Quality Assurance visit report November 2016, Public Health
England
Recommended action plan from the Never Event
Programme Management Data
2019 Workforce Planning Meeting Notes
Breast Screening Workforce Plan 2019-2020
Consultant skills and competencies
KPI monitoring 2017/18 data, Public Health England
NHSBSP & ABS audit of screen detected cancers 1 April 2016 to 31 March
2017 and 1 April 2014 to 31 March 2017, Public Health England
National Audit of Breast Cancer in Older Patients 2018 Annual Report
National Audit of Breast Cancer in Older Patients 2019 Annual Report
Protocol for Localisations
Breast 2WW Pathway
Breast Screening Assessment Pathway
Breast Screening Pathway
Northampton Breast Screening Service QA Team Visit – 3 November 2016,
Public Health England
Letter to Chief Executive Northampton breast screening quality assurance visit
outstanding recommendations for action, Public Health England
MDT Discrepancy Meeting Cases
Kettering & Northampton Breast Cancer Screening Programme Board Meeting
8 August 2018, NHS England
Internal email from Programme Manager regarding outstanding QA
recommendations
Interpreting, Translating and Language Support Services Guideline
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Northampton Breast Screening Service Client Satisfaction Survey – March
2019
Work instructions for the booking of the interpreting service
Surgery Breast Complaints June 2018 – June 2019
Breast Cancer Multi-Disciplinary Team Operational Policy 2019
Breast Cancer Nurse Job Description Band 6
Breast Cancer Nurse Person Specification Band 6
Breast Cancer Nurse Job Description Band 7
Breast Cancer Nurse Person Specification Band 7
Breast MDT Attendance 2018
Complaint (1) 101018
Complaint (2) 180619
Complaint (3) 220319
Complaint (4) 200319
Complaint (5) 240119
Breast Surgery Forrest Centre Compliments
Breast Surgery Forrest Centre Monthly Performance July 2018 to June 2019
Monthly Cancer Performance Figures June 2019 (not validated)
Monthly Cancer Performance Figures July 2019 (not validated)
Trust Level Performance Summary – 12th July 2019
General & Specialist Surgery Clinical Governance Meeting Minutes 15th April
2019
General & Specialist Surgery Clinical Governance Meeting Minutes 17th June
2019
General & Specialist Surgery Clinical Governance Meeting Minutes 20th May
2019
Multidisciplinary Breast Cancer Meeting Discrepancy Meeting 27th June 2019
Reconstruction surgeries data
Patient Survey / Audit Request Form
Audit on 50 NACT (Neoadjuvant chemotherapy) patients
Breast Implant Audit
National Cancer Patient Experience Survey 2017 Results
A closed loop audit looking at the specimen weight of open diagnostic excision
of screen-detected probably benign breast legions
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Cancer Patient Experience Survey January – May 2019
Fourth Consultant Breast Surgeon Business Case
Equality & Diversity Service Annual Report April 2017 – March 2018
Equality & Diversity Service Annual Report April 2016 – March 2017
Post-investigation letter to patient
SI / CI summary
The following documents were provided as evidence to the clinical review team
subsequent to the panel on 19th July:
Current 18ww data for breast surgery
Breast suspected cancer 2ww referral form
In addition:
Dr Lucy Gavens and Dr Rebecca Hall submitted presentation slides to the
clinical review team on their research findings
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Appendix C: Clinical review team members and their biographies, and any conflicts of interest
Name Role Organisation Conflict of interest
Ben Anderson Deputy Director for
Healthcare Public
Health
Public Health
England East
Midlands
None
Dr Julie Attfield Executive Director
Nursing
Clinical Senate Vice
Chair
Nottinghamshire
Healthcare NHS
Trust
None
Miss Nadine
Betambeau
Consultant
Oncoplastic Breast
Surgeon
St George’s Hospital,
London
None
Dr Ann Boyle Associate
Postgraduate Dean
Health Education
England East
Midlands
None
Charles Carroll Cancer Centre
Manager
United Lincolnshire
Hospitals NHS Trust
None
Susan Edge Patient
Representative
East Midlands
Clinical Senate
None
Dr Lucy Gavens Specialty Registrar
in Public Health
University Hospitals
of Derby and Burton
Clinical Senate
Fellow
None
Dr Rebecca Hall GP Charnwood
Community Medical
Group
Clinical Senate
Fellow
10 years ago, I
was an FY1 to
Mr Dawson at
NGH
Mr Jonathan Lohn Consultant Plastic St George’s Hospital, None
Page | 40
and Reconstructive
Surgeon
London
Jackie O’Sullivan Breast CNS Nottingham
University Hospitals
NHS Trust
None
Mandy Rudczenko Patient
Representative
East Midlands
Clinical Senate
None
Mr Martin Vesely Consultant Plastic
Surgeon
St George’s Hospital,
London
None
Clinical Senate Support TeamMs Emma Orrock – Head of East Midlands Clinical Senate, NHS England and NHS
Improvement
Miss Lara Harrison – Clinical Senate Administrator, NHS England and NHS
Improvement
Page | 41
Biographies
Ben Anderson Ben is PHE’s Deputy Director for Healthcare Public Health in the East Midlands,
responsible for a team that supports the NHS and local authorities on all aspects of
healthcare public health including specific support to NHS England on specialised
commissioning, dental public health, health and justice and screening and
immunisation services. Ben also leads on Knowledge and Intelligence within the PHE
Centre and is the Executive sponsor of the Centre’s Deep Dive programme which
has produced reports on Health Inequalities, Alcohol, Cancer, Early Years (0-5),
CVD, TB and Health and Justice since its inception.
Prior to joining PHE in 2014 Ben trained in Public Health in Yorkshire and Humber,
including working with the DH’s Health Inequalities National Support Team, and
worked as a Public Health Consultant in the NHS and Local Government in both
Yorkshire and Humber and the East Midlands. He continues to be passionate about
tackling health inequalities and the delivery of local solutions through collaboration
and system leadership. In his current role, he works closely with all of the East
Midlands Partner Organisations and over the past 3 years he has led a joint
programme of work with the East Midlands Clinical Senate on Prevention in response
to the NHS Five Year Forward View. This work has supported the development of a
holistic view of prevention in the East Midlands and a set of diagnostic tools for
providers and commissioners to assess their progress against the national ambition
for a “radical upgrade in prevention and public health”. Ben is a Fellow of both the
Faculty of Public Health and the Higher Education Academy and contributes to Public
Health Training as the Training Programme Director for Quality within the East
Midlands School of Public Health. Ben is co-chair of the East Midlands Healthcare
Public Health Community of Improvement and CVD Prevention Steering Groups and
Chair of the Advisory Group for the Sheffield NIHR School for Public Health.
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Dr Julie Attfield RMN, BSc (Hons), MSc, MA, PhD Executive Director Nursing, Nottinghamshire Healthcare NHS TrustClinical Senate Vice-Chair Julie is the Executive Director of Nursing for Nottinghamshire Healthcare NHS
Foundation Trust. The Trust is a major provider of mental health, intellectual disability
and community healthcare services for the people of Nottinghamshire. It sees in the
region of 190,000 people every year and its 8,800 staff carry out a wide range of
roles; working together to provide integrated and coordinated care. Julie began her
career as a Registered Mental Health Nurse, and has since worked as a clinician,
senior manager and director within mental health services in the East Midlands.
Between these appointments, Julie spent time as a lecturer in Nursing at the
University of Nottingham, before returning to the NHS. Julie’s role prior to taking up
this position was Director of Nursing and Operations at Lincolnshire Partnership NHS
Foundation Trust and the Executive Director of Forensic Services in the Trust. Julie
has made a number of professional contributions and gained accolades including
holding the title of Queen’s Nurse, being a Senior Fellow of the Institute of Mental
Health and company secretary for the National Mental Health Nurse Directors Forum.
Julie is professionally known particularly for her research into the use of care
pathways in mental health, service redesign, quality improvement and governance.
Miss Nadine Betambeau BSc (Hons) 1995, MBBS (London) 1998, MD (London) 2010, FRCS (England) 2011 Member of the Association of Breast Surgeons (ABS)Miss Nadine Betambeau graduated from St George's Hospital Medical School in
1998 and undertook her surgical training in South West Thames. She studied for her
Doctor of Medicine (MD) degree at the Royal Marsden Hospital and the Institute of
Cancer Research, before completing her surgical training in the Bristol and South
West England region.
Miss Betambeau completed a two-month fellowship under the supervision of Mr
Krishna Clough, World renowned breast and plastic surgeon at The Breast Institute
in Paris in 2012. She has been a consultant oncoplastic breast surgeon at St
George's Hospital since July 2012.
Miss Betambeau offers a full range of oncoplastic breast-conserving surgical
procedures, implant-based reconstruction and LD muscle flap based breast
Page | 43
reconstruction. She also undertakes collaborative operating with Plastic Surgeons for
free-flap breast reconstructions. In addition, she operates to correct congenital and
other causes of breast asymmetry, and in those patients who require breast
augmentation or breast reduction surgery.
Dr Ann Boyle MB BCh BAO National University of Ireland MRCPsych FRCPsych Honorary Associate Professor Leicester Medical School Ann is a Consultant old age psychiatrist employed at Leicestershire Partnership NHS
Trust. Ann has been involved in medical education throughout her consultant career
across the continuum of undergraduate and postgraduate training working as a
clinical tutor, training programme director and Head of school of Psychiatry. Ann is
currently working as an Associate Postgraduate Dean at Health Education East
Midlands and as clinical block lead for Integrated Care Block at Leicester Medical
School. Ann contributes nationally as the Specialist Advisor for the Foundation
Programme at the RCPsych.
Charles Carroll Charles is the Cancer Centre Manager at United Lincolnshire Hospitals, one of the
largest cancer treating trusts in the country and has been in this role since 2012. He
studied engineering at Huddersfield and has worked in a variety of industries, before
joining an acute trust’s Information Department in 2014. Within the NHS, he has
worked in operational and support roles and has undertaken both the NHSI Quality,
Service Improvement and Redesign course and the NHSI Elective Care Essentials
for Cancer programme.
Charles is a keen advocate of the adoption of cancer management software being
used as standard, trust-wide systems (as opposed to being for Cancer Centre use
only) and regularly presents at regional conferences on this subject.
Ms Susan Edge, Lay Member – Patient and Public Involvement Susan was involved in the further, adult and work-based learning sector for over 30
years, working in a variety of different organisations both public and voluntary.
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Her roles have ranged extensively, from frontline delivery as a lecturer, to strategic
responsibilities for ensuring certain qualifications in England and Wales met
regulatory requirements. In addition, Susan has worked on national quality initiatives,
and for several inspectorates. She brings to her position at Lincolnshire West CCG
and the LMS her experience of involving learners in their provision, and of quality
assurance and improvement.
Susan is also a lay partner for Health Education England across the East Midlands
as well as for the National Institute for Health Research. She is a member of the
EMAHSN PPI Senate as well as chair of governors of a local junior academy, and a
Trustee of soundLINCS.
Dr Lucy Gavens Lucy is a Specialty Registrar in Public Health with over 10 years’ experience in Public
Health Research and Practice.
Lucy’s expertise is in assessing the health and healthcare needs of populations and
developing strategies to meet those needs. She works with stakeholders across a
number of organisations including Local Authorities, Public Health England, NHS
Commissioners, NHS Providers, and the Community and Voluntary Sector, to advise
on and influence the commissioning and delivery of a range of public health and
healthcare services.
She operates across a broad range of Public Health priority areas; her specialist
interests are in the fields of substance misuse and physical activity. Lucy has
considerable research experience, having worked on a range of quantitative and
qualitative research projects in the field of substance misuse at the University of
Sheffield.
She has a PhD in Public Health, completed in 2013, during which she examined
psychological theories of health behaviour with reference to alcohol consumption in
older adults.
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Dr Rebecca Hall BSc (Hons), MBChB, MRCP(UK), MRCGP, DRCOG Rebecca is a General Practitioner in Loughborough, Clinical Fellow with Health
Education East Midlands and Clinical Fellow with the East Midlands Clinical Senate.
Rebecca graduated from University of Warwick in 2002 with a Bachelor of Science in
Chemistry and Medicinal Chemistry. She then commenced her medical degree with
the University of Leicester, graduating in 2007.
Rebecca undertook core medical training in Nottingham prior to deciding that due to
having broad interests in all aspects of medicine, a career in General Practice was
where her future lay.
Rebecca completed her General Practice training in 2014. She was successfully
appointed as a partner at Charnwood Medical Group in 2016 where she continues to
practice. One of the key benefits to a career in General Practice was the flexibility it
offers to allow pursuit of a variety of roles.
Since 2014 Rebecca has been able to balance her clinical interests with a desire to
have closer links between primary and secondary care for patients and has
undertaken a number of clinical fellowships to develop these interests.
Currently Rebecca is working with Leicestershire Partnership Trust to enhance and
develop GP trainee knowledge and experience of the holistic care of patients with
mental health needs.
Mr Jonathan LohnMr Lohn is a Consultant Plastic and Reconstructive surgeon at St George’s Hospital,
London, where he specialises in complex reconstructive microsurgery after cancer
and trauma. He graduated from University College London in 2001 having been
awarded the Betuel Prize, in addition to distinctions in Surgery, Medicine,
Pharmacology, Gynaecology and Obstetrics. He subsequently undertook his training
in Plastic Surgery within London working at renowned units including St Andrew’s
Centre for Burns and Plastic Surgery, Chelmsford, and the Queen Victoria Hospital,
East Grinstead. His UK training culminated in the award of full accreditation in Plastic
Surgery by The Royal College of Surgeons of England, FRCS (Plast). Specialist
interests were developed with a Cosmetic Fellowship at the prestigious Wellington
Hospital in London, followed by a Fellowship in Complex Reconstruction
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Microsurgery of the breast, head and neck, limbs and Aesthetic surgery at the
acclaimed Royal Melbourne Hospital, where modern plastic surgery techniques were
and still are pioneered.
Jackie O’Sullivan, RN, BScJackie is a Clinical Nurse Specialist (CNS) in Breast for over 20 years. Qualified in
1993 with early career in general surgery, mainly major Bowel, Breast and
Orthopaedic surgery. Jackie worked also for a short period in HIV/AIDS, then
specialised in Breast.
Jackie trained in London and worked in three different Breast Units, whilst completing
a BSc in Cancer Nursing at The Royal Marsden.
Jackie moved to the Nottingham Breast Institute in 2005 as a CNS in Breast and
recently worked for 5 months on secondment as assistant Lead Cancer Nurse and
she is also a reviewer internally and externally for Quality Surveillance.
Jackie’s main interests/passions are Health Promotion and Exercise in Cancer
Nursing, Ethnicity and awareness and Patient Pathways.
Jackie’s qualifications: RGN, ENB 998, END 934, Diploma in Breast Care Nursing,
BSc in Cancer Nursing, Advanced Communication Skills, Level 2 Psychological
Training, Foundation In Psychotherapy.
Amanda RudczenkoPatient representative A former mental health nurse and adult education tutor, Mandy has been helping her
son to manage his Cystic Fibrosis for the past 17 years. She first became involved in
Patient and Public Involvement work as a lay member on a Clinical Reference Group
for Cystic Fibrosis. Over the past 4 years Mandy has become an active campaigner
for the co-production of health and social care services, person-centred care, shared
decision making, and self-management of long-term conditions. As a member of the
Co-Production Team with the Coalition for Collaborative Care, Mandy has
contributed to the design and co-production of many projects, including The Reading
Well scheme. Mandy has also served as an Expert by Experience on NHS England’s
Five Year Forward View People and Communities Board, helping to co-design the
‘six principles for engaging people and communities’. Mandy is an active member of
The Q Community (The Health Foundation). Her work has included co-convening the
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Special Interest Group in Coproduction, contributing to the QLab project on Peer
Support; chairing tweet chats. As a member of the East Midlands Patient and Public
Involvement Senate, Mandy has co-designed and delivered training in Coproduction.
She is also a public contributor on a research panel with the National Institute for
Health Research.
Mr Martin Vesely BM BCh, DM, FRCS(Plast)Mr Vesely is a senior consultant Plastic Surgeon at St. George’s Hospital, London.
He qualified from Cambridge and Oxford Universities in 1991. His plastic surgical
training was in Oxford and London, with research at the RAFT Institute at Mount
Vernon Hospital, and fellowships in cancer reconstruction at the Royal Marsden
Hospital and the Toronto General Hospital, Canada. He was awarded the Hunterian
Professorship by the Royal College of Surgeons of England in 2000. He has
previously been the departmental lead clinician at St. George’s, is a past-president of
the Plastic Surgery Section of the Royal Society of Medicine and is also an examiner
for the clinical Part 3 of the FRCS(Plast). He is a member of the Breast Cancer MDT
at both St. George’s Hospital, London and Ashford & St. Peter’s Hospitals, Surrey.
He provides an immediate and delayed complex reconstructive breast surgery
service to his breast surgery colleagues from both Trusts, as well as offering help
and advice with other difficult breast surgery problems.
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