Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0190, written 20 Mar 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Mar 2014 |
|---|---|
| Reference | 2014-0190 |
| Deceased | Robert Jones |
| Coroner | Jonathan Layton |
| Coroner area | Carmarthenshire and Pembrokeshire |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive of West Wales General Hospital Glangwili Carmarthen 1 CORONER I am Jonathan Mark Layton senior coroner, for the coroner area of Carmarthenshire and Pembrokeshire. 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 14th May 2013 I commenced an investigation into the death of Robert Erryl Jones then aged 62. The investigation concluded at the end of the inquest on 18th March 2014. The conclusion of the inquest was a narrative conclusion namely that the deceased had died as a result of complications following necessary bowel surgery. The medical cause of death was: 1(a) multi-organ failure 1(b) peritonitis 1(c) post surgery for bowel cancer 4 CIRCUMSTANCES OF THE DEATH (1) Mr Jones was admitted to Glangwili Hospital on 21st March 2013 for a bowel operation which was undertaken the following day. Mr Jones remained in hospital following the operation. (2) Due to his declining health an emergency CT scan was arranged for the 8th May 2013. (3) There was an unreasonable delay in making the results of the CT scan available to the ITU and Surgical teams involved in Mr Jones’ care. The report was not written up for some considerable time after the scan. (4) When the results were made available there was a further unreasonable delay on the part of the ITU and Surgical teams in acting upon those results. (5) This led to a significant delay in further surgery being performed. (6) It became evident during the course of the inquest that this was not an isolated incident and this failure to pass over and act on CT scan results continues to occur. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed this matter 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. 1 The MATTERS OF CONCERN is as follows: That when a CT scan is performed the results should be made available promptly to the departments involved in the care of the patient and where appropriate the results should be acted upon without delay and within a reasonable time-scale. 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 the 15th May 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 Person: 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 20 March 2014 Signed: 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.
Q G IG Bwrdd lechyd Prifysgol eye N HS Hywel Dda University Health Board Swyddfeydd Corfforaethol, Adeilad Ystwyth Eich cyf/Your ref: JML/343-13 Hafen Derwen, Parc Dewi Sant, Heol Ffynnon Job Gofynnwch am/Please ask for: Patient Support Services Caerfyrddin, SA31 3BB Rhif Ff6n /Telephone: 0300 0200 159 E-bost/E-mail: hdhb.patientsupportservices@wales.nhs.uk Corporate Offices, Ystwyth Building ; i Hafen Derwen, St Davids Park, Job’s Well Road, Dyddiad/Date: 14° July 2014 Carmarthen, SA31 3BB Mr M Layton HM Coroner for Pembrokeshire & Carmarthenshire Coroner’s office Town Hall Hamilton Terrace Milford Haven Pembrokeshire SA73 3JW Dear Mr Layton Inquest into the death of Robert Erryl Jones Thank you for your letter received by this office on 27 March 2014, enclosing a report pursuant to Regulation 28 of the Coroners (investigations) Regulations 2013. Please accept my apologies for the delay in responding to your letter. The Health Board fully recognises the need to ensure CT scan results should be made available promptly and will ensure that this is routinely monitored. The Radiology department will be undertaking sampling of the scan to report time for emergency CT scans. All staff will be reminded of the need to ensure that the results of any diagnostic test that is requested must be reviewed by the clinical team responsible for requesting the test. It must be documented in the patient’s notes that the results have been reviewed and any resultant action recorded. Any test results which are given verbally, as maybe the case in an emergency situation, must also be appropriately documented in the patient record. We will also ensure that where patients maybe under the care of several different clinical teams that test results are made available to any members of those teams. The Medical Director of the Health Board will also be including this information in her regular updates to all clinical staff. i i ildi ‘dd / Chair Swyddfeydd Corfforaethol, Adeilad Ystwyth, Corporate Offices, Ystwyth Building, Cadeiry ‘ Hafan Derwen, Parc Dewi Sant, Heol Ffynnon Job, Hafan Derwen, St Davids Park, Job’s Well Road, Mrs Bernardine Rees OBE Caerfyrddin, Sir Gaerfyrddin, SA31 3BB Carmarthen, Carmarthenshire, SA31 3BB Prif Weithredwr/Chief Executive Mrs Karen Howell Bwrdd lechyd Prifysgol Hywel Dda yw enw gweithredol Bwrdd lechyd Lleol Prifysgol Hywel Dda Hywel Dda University Health Board is the operational name of Hywel Dda University Local Health Board Mae Bwrdd lechyd Prifysgol Hywel Dda yn amgylchedd di-fwg Hywel Dda University Health Board operates a smoke free environment I confirm that a report on these actions will be presented to the Health Board’s Putting Things Right Committee in September. I will write to you further with an update following this meeting. If you require any further information in the meantime, please do not hesitate to contact me. Yours sincerely Karen Howell Chief Executive (interim) Cc | on Independent Member & Chair of the Putting Things Right Committee
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