Sally Ellison

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

Governance Support Manager for the Pathology Clinical
Programme Group, Glan Clwyd Hospital, Sarn Lane, Bodelwyddan.

1 CORONER

lam 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 7th of June 2012 | commenced an investigation into the death of Sally Ellison
(DOB 3.8.57, DOD 1.6.12). The investigation concluded at the end of the inquest on the
24" of April 2015 and | recorded a conclusion of an Accidental death

4 | CIRCUMSTANCES OF THE DEATH
The Circumstances of the death are that Mrs Ellison contracted the legionella infection

whilst on holiday in Tunisia in Mid-May 2012 and her death on the 1* of June 2012 was
due to 1(a) Cardiac Arrest (b) Multi Organ Failure (c) Legionella Pneumonia

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. That urgent blood tests were requested By  coxecamsetetie at lunchtime on the
28" of April 2012, yet despite these being noted as urgent, the samples were
not conveyed to the laboratory for analysis after collection by the district nurse,
until a routine collection of samples was undertaken from Colwyn Bay
Community Hospital later that afternoon. As a result the delay in analysis meant
that results were not provided to surgery until the following morning. Whilst the
evidence indictates that changes have been made within the laboratory at Glan
Clwyd to enable the immediate reporting of all cases where the CRP is greater
than 300, there was no evidence available to confirm that all urgent tests could

be expedited by district nurses thus alleviating potentially life threatening delays
in treatment.

6 | ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe your
organisations 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 22™ June 2015 |, 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

| have sent a copy of my report to the Chief Coroner and to the following Interested
Person — (J (Husband of the Deceased)

lam 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.

\ GIG Bwrdd lechyd Prifysgol
> CYMRU | Betsi Cadwaladr

Qe N H S University Health Board

WALES

Patholeg, Ysbyty Glan Clwyd, Y Rhyl, Sir Ddinbych, LL18 5UJ
Pathology, Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ

Mr. J Gittins Eich cyf / Your ref: Letter of 27" April 2015
HM Senior Coroner for North Wales

(East and Central) Ba: PF
HM Coroner’s Office Gofynnwch am _/

County Hall E-bost / Email:

Wynnstay Road Dyddiad / Date: 19" June 2015

Ruthin

LL15 1YN

Dear Mr. Gittins,

Re. report for the Prevention of Future Deaths
Inquest of Sally Ellison

Following the conclusion of the above inquest you sent me a report pursuant to
Regulation 28 of the Coroners (Investigations) regulations 2013. In this Report you
reported that the MATTERS OF CONCERN were as follows:-

That urgent blood tests were requested by cP) at lunchtime on the 28"
of April 2012, yet despite these being noted as urgent, the samples were not
conveyed to the laboratory for analysis after collection by the district nurse, until a
routine collection of samples was undertaken from Colwyn Bay Community Hospital
later that afternoon. As a result the delay in analysis meant that results were not
provided to surgery until the following morning. Whilst the evidence indicates that
changes have been made within the laboratory at Glan Clwyd to enable the
immediate reporting of all cases where the CRP is greater than 300, there was no
evidence available to confirm that all urgent tests could be expedited by district
nurses thus alleviating potentially life threatening delays in treatment.

From this, you have requested that actions should be taken to prevent future deaths.
Because of this, the Pathology Clinical Programme Group (CPG), and in particular
the Governance section of the CPG, has reviewed the process for the requesting of
urgent samples from primary care across BCUHB. This process has been explained
in a memorandum _—_ that will be distributed electronically to all GPs and
Practice Managers supported by BCUHB. The memorandum includes the correct
process for the labeling of samples and its transportation to minimise delay. It also
includes the relevant departmental telephone numbers for the laboratories across
North Wales to ensure that the sample requester can warn the relevant department
of the samples imminent arrival.

Our colleagues in the Primary Care Support Unit will enable this distribution which
will take place during the week commencing Monday 224 June 2015. | will write to
you subsequently to confirm this distribution has taken place.

Yours faithfully,

Governance Support Manager
Pathology CPG