Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0302, written 2 Jul 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jul 2014 |
|---|---|
| Reference | 2014-0302 |
| Deceased | Ronald Perry |
| Coroner | John Gittins |
| Coroner area | North Wales (East & Central) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW 1 | CORONER | am JOHN ADRIAN GITTINS, senior coroner, for the coroner area of North Wales (East and Central)] 2 | CORONER’S LEGAL POWERS | 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 the 21 of January 2014 | commenced an investigation into the death of Ronald Perry (DOB 22.11.1955 DOD 18.01.2014). The investigation concluded at the end of the inquest on the 19" of June 2014 and | recorded a conclusion of Natural Causes with the cause of death being 1(a) Ruptured Atheromatous Aortic Aneurysm 4 | CIRCUMSTANCES OF THE DEATH The Circumstances of the death are that the Deceased had attended at Glan Clwyd Hospital, Bodelwyddan on the 17"” of January 2014 and that following examination at their Emergency Department was discharged home. Several hours later he collapsed, was readmitted but could not be resuscitated. 5 | CORONER’S CONCERNS During the course of the inquest, evidence given » iii BED i cicatcd that had the Deceased undergone a CT scan then it is probable that his aneurysm would have been detected and that he would have undergone surgery. However different criteria exist within BCUHB by which CT scans can be requested by clinicians dependent upon the time of day (before or after 5.00 pm) or whether such a request is made at a weekend. The MATTERS OF CONCERN are as follows :- That unless steps are taken to provide consistency within the levels of care provided to patients on a 24 hour basis then there will be continuing risks to patients “out of hours” and may lead to future deaths. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 August 2014 |, 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. COPIES and PUBLICATION | have sent.a copy of my report to the Chief Coroner and to the following Interested Person — (Wife of the Deceased) | 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. [DATE] 2™ July 2014 [SIGNED BY CORONER]
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.
Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd, LL57 2PW GIG Bwrdd lechyd Prifysgol We? Betsi Cadwaladr H nN FA ALES University Health Board Gwynedd Hospital, Penrhosgarnedd, Bangor, Gwynedd, LL57 2PW PRIVATE & CONFIDENTIAL Ein oyf / Our ref: P| Eich cyf / Your ref: Mr J Gittins HM Senior Coroner for North Wales (East Rhif Ffon/ Phone: @: Ld and Central) Gofynnwch am / Ask for: PY HM Coroner's Office, Ffacs / Fax: County Hall -bost/Emal: es Wynnstay Road, E-bost / Email: Ruthin Dyddiad / Date: 02 September 2014 LL15 1YN Dear Mr Gittins Re Regulation 28 ~ Report for the prevention of deaths — Inquest of Ronald Perry Following the receipt of your letter dated the 2"° July 2014 the Radiology Clinical Programme Group on behalf of Betsi Cadwaladr University Local Health Board (BCULHB) has reviewed the services provided and would seek to provide the assurances you requested. During the inquest of Mr Ronald Perry, HE gave evidence that there are variations in the referral criteria for Computerised Tomography (CT) scanning within BCUHB depending upon the time of day. It was this evidence that gave rise to the concerns that access to scanning “out of hours” may lead to future deaths. The Radiology service at all three district general hospital’s in North Wales operates a full service Monday to Friday 8.30 am to 5.30pm with some scanning lists being extended into the evenings. This comprises of lists with booked outpatients, urgent suspected cancer patients, inpatients and clinical emergencies. At all other times a general X-ray service is offered alongside an emergency on call service for CT and ultrasound scanning. The emergency on call service is provided on a consultant to consultant basis for all cases where scanning is required to manage an emergency or life threatening condition. In the case of Mr Ronald Perry the Radiology Clinical Programme Group understand that a diagnosis of possible ruptured abdominal aortic aneurysm was not one of the considered differential diagnosis. The clinical directors for all three departments have confirmed that a request for this clinical indication would have resulted in a CT scan being performed as an emergency at any time during the 24 hour period when the referral was made. In Mr Perry's case no request was made to radiology for a scan to be performed. As part of continued improvements to the service the Radiology Clinical Programme Group is working to develop increased access outside of normal office hours. However, in this particular case had a referral been made with a clinical indication of possible dissecting or ruptured abdominal aortic aneurysm the level of urgency would have resulted in an urgent scan being performed, whether in or out of normal working hours. Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives' Office, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk 7Q4\ GIG Bwrdd lechyd Prifysgol [YM Betsi Cadwaladr U OF N S University Health Board WALES If you feel it would be helpful to discuss this response in more detail please contact |_| a Interim Chief of Staff for Radiology. [EE can be contacted either by telephone, The Radiology Clinical Programme group hope that this response provides you with the reassurance that all patients who are referred for CT scanning with an emergency life threatening condition are treated in the same way, irrespective of the time. Yours sincerely ANGELA HOPKINS Signed by the Executive Director of Nursing and Midwifery on behalf of the Chief Executive CC mz - Chief of Staff, Radiology Clinical Programme Group HE ~~ Associate Chief of Staff (Operations), Radiology Hs — Hlcad of Quality & Governance Radiology
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