Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0372, written 17 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Dec 2013 |
|---|---|
| Reference | 2013-0372 |
| Deceased | John Morgan |
| Coroner | John Woolley |
| Coroner area | Cardiff & the Vale of Glamorgan |
| Category | Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mark Drakeford AM, Minister of Health, Welsh Assembly Government 2. , Clinical Director, Community Mental Health Services for Older People, Llandough Hospital 1 CORONER I am Christopher John Woolley, Assistant Coroner, for the Coroner area of Cardiff and the Vale of Glamorgan 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 9th September 2013 I commenced an investigation into the death of John Elvet Morgan aged 88. The investigation concluded at the end of the inquest on 26th November 2013. The medical cause of death was: 1A Pulmonary Embolism in a man with dementia of Alzheimer’s type, and the conclusion of the inquest was that the deceased died from natural causes. 4 CIRCUMSTANCES OF THE DEATH John Elvet Morgan was admitted to St Barruc’s ward, Barry hospital on 29th August 2013 for respite care. He suffered from Alzheimer’s dementia. On admission a red DNR (Do not Resuscitate) star was allowed to remain against his name on the whiteboard (or PSAG “Patient status at a glance Board”) on the ward. In fact there had been no agreement that he was “DNR” and the red star had been left over by mistake from a previous patient’s entry on the whiteboard. On 30th August 2013 John Elvet Morgan collapsed on the ward. He was not resuscitated by staff on the ward as they relied on the red “DNR” star on the whiteboard. When the paramedics arrived no yellow DNR form was found in the notes as of course one did not exist. The PM report showed that John Elvet Morgan had suffered a pulmonary embolism. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the Clinical Director for the University Hospital for bedside “TCAB” programme. Dr Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the 1 whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales. (2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes. (3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care. (4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th February 2014. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. Cardiff and Vale University Health Board who may find it useful or of interest. . I have also sent it to Medical Director, I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 17th December 2013 C J Woolley, Assistant Coroner 2
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mark Drakeford AC / AM IEE Y Gweinidog lechyd a Gwasanaethau Cymdeithasol a Minister for Health and Social Services wy, wa Llywodraeth Cymru Welsh Government Eich cyf/Your ref Ein cyf/Our ref MB/MD/0220/14 Mr C J Wooley Assistant Coroner The Coroner’s Court Central Police Station Cathays Park Cardiff [© February 2014 CF10 3NN Deehy etl, | write further to your Regulation 28 Report in relation to the inquest into the death of Mr John Elvet Morgan. | was extremely concerned to read the circumstances of Mr Morgan’s death whilst a patient at Barry Hospital and offer my sincere condolences to his family. As you describe in your report the Patient Status at a Glance (PSAG) board is useful as a reference point for patient care. However, | am in agreement with you, the information recorded must be accurate and staff must not rely solely upon this information when making decisions about a patient's care and treatment. | expect Health Boards and Trusts to have suitable systems in place to ensure the safety of patients at all times and within all clinical areas. Action The incident was reported to Welsh Government under the Serious Patient Safety Incident reporting process in September last year. The Chief Nursing Officer for Wales issued a request to all Nurse Directors within Health Boards and Trusts requesting they consider the circumstances of the incident and make changes to their systems as appropriate. | have further requested the Chief Medical Officer and Chief Nursing Officer write to all Health Boards and Trusts in Wales to remind them, where PSAG boards are in use, robust systems must be in place to safeguard patient safety and prevent a similar incident from happening again. Bae Caerdydd « Cardiff Bay English Enquiry Line 0845 010 3300 Caerdydd « Cardiff Llinell Ymholiadau Cymraeg 0845 010 4400 CF99 1NA Correspondence.Mark.Drakeford @wales.gsi.gov.uk Wedi’i argraffu ar bapur wedi’i ailgylchu ( 100%) Printed on 100% recycled paper Welsh Government officials will also bring this to the attention of the 1000 Lives improvement service, our national quality improvement programme, so that they can reinforce the importance of healthcare staff using accurate information within any future guidance they provide. This is a very serious matter. | will ask the NHS Wales Quality and Safety Forum to discuss this at their next meeting to reinforce the learning. =) ows SH Cwre? Mark Drakeford AC / AM Y Gweinidog lechyd a Gwasanaethau Cymdeithasol Minister for Health and Social Services
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