Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0097, written 9 Mar 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Mar 2016 |
|---|---|
| Reference | 2016-0097 |
| Deceased | John Rogers |
| Coroner | John Adrian Gittins |
| Coroner area | North Wales (East and 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.
John Adrian Gittins Senior Coroner for North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW CORONER lam John Adrian Gittins, Senior Coroner for North Wales (East and Central) 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. INVESTIGATION and INQUEST On 31/03/2015 | commenced an investigation into the death of John William Rogers, (DOB12.7.36 DOD 28.3.15) The investigation concluded at the end of the inquest on 08 March 2016. The conclusion of the inquest was one of Natural Causes, the Cause of Death being recorded as 1(a) Left Ventricular Failure (b) Myocardial Infarction (c) Occlusive Coronary Artery Atheroma CIRCUMSTANCES OF THE DEATH The Deceased was admitted to Glan Clwyd Hospital on the 25 of March 2015 and in the early hours of the 28th of March was found collapsed on the floor near to his bed following a cardiac arrest. In the course of the subsequent resuscitation attempts the defibrillator was set on 2 joules rather than the required 150 joules yet although this error was identified by nursing staff after around 30/40 minutes they did not advise the crash team of this. The defibrillator was being controlled at the time of this error by a member of the nursing staff who was operating the machine on a manual setting for the first time and whose Advanced Life Support qualification (obtained more than four years before) had expired the previous month. 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. — That the current systems in place within BCUHB are not sufficiently robust to ensure that their staff are appropriately qualified to undertake the work required of them and that their training and qualifications remain up to date. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | Fax 01824 708048 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have 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 03/05/2016. |, 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 legal representatives of following Interested Persons — The a 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. Dated 08 March 2016 Senior Coroner tor North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | Fax 01824 708048
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.
- Block 5, Carlton Court La GIG | awrad lechyd Prifysgol St Asaph Business Park AY CYMRU | Betsi Cadwaladr st Asaph 7 vers} enbighshire 24 WALES University Health Board LL147 0JG Private and Confidential Ein cyf / Our ref: | Mr John Gittins Eich cyf/ Your ref: Senior Coroner : H.M. Coroner’s Office B: fF County Hall Gofynnwch am / Ask for: Wynnstay Road E-bost / Email: Ruthin Dyddiad / Date 3° May 2016 LL15 1YN Dear Mr Gittins, RE: Report for the Prevention of Future Deaths - Inquest of John William Rogers Further to your letter dated 14 March 2016, please find below the Health Board’s response to the Regulation 28 requirements which, in this case, particularly relates to the concerns "that the current systems in place within BCUHB are not sufficiently robust to ensure that their staff are appropriately qualified to undertake the work required of them and that their training and qualification remain up to date". We have focused on two clear aspects in order to respond to your concerns following this Inquest. The first being the detailed action plan relating to Ysbyty Glan Clwyd and the specific training requirements relating to the Inquest and secondly, the wider application of your concern, which is focused on the BCUHB wide training systems to ensure that all staff are appropriately qualified to undertake the work required of them and that their training and qualifications remain up to date. | have therefore included in the attached documents, the detailed action plan demonstrating actions which have been undertaken and completed, subsequent to the death of John William Rogers, to provide assurance relating to the training and appropriate qualifications of the staff on the unit and also for related on-call arrangements and rotas. The second document, included within this response, provides clarity of the policy and procedure frameworks supporting training and qualifications for all staff across the Health Board and covers the systems and processes which the Health Board have in place to provide assurance on the training and qualification status for all staff members. In reviewing the training framework and policies with colleagues, there are a range of actions which have been proposed and agreed within the Senior Managers and Executive Team, which will strengthen the current systems and processes to ensure training and qualifications status remain up to date (current) for the clinical area within which they work. To ensure that there are no lapses to training and qualifications, the Health Board has introduced a more rigorous approach to monitoring as well as a supportive and flexible approach for staff to complete their mandatory training. 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 Le Bwrdd lechyd Prifysgol “ af i q U | Betsi Cadwaladr WF N University Health Board WAL ae s The outcome and status of mandatory training and maintenance of core clinical skills has and will remain a priority for the Health Board and is part of the Health Board's monthly performance reporting. This is actively monitored through the Clinical Accountability meetings held with each Hospital and area teams and is subsequently reported through to the Health Board. Please be assured that the Health Board is monitoring training compliance to ensure that staff are appropriately qualified to undertake their role. Yours sincerely (aq Che Gary Doherty Prif Weithredwr Chief Executive Encl.
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