Pamela Conway

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

Chief Executive, BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57
2PW

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 13> of November 2014 | commenced an investigation into the death of Pamela
June Conway (DOB 13.6.43, DOD 8.11.14). The investigation concluded at the end of
the inquest on the 23” of August 2016 and | recorded a conclusion that the death was
due to natural causes which were exacerbated by delayed medical treatment.

4 | CIRCUMSTANCES OF THE DEATH

The Circumstances of the death are that for multifactorial reasons there was a delay of
around 21 hours before the deceased received antibiotics for an infected knee and that
during the course of this period she went into irrecoverable septic shock.

Amongst the reasons for the above delay was the length of time it took for Mrs Conway
to be discharged from the ambulance to the hospital on the 10" of October 2014. On this
date the emergency department at Wrexham Maelor Hospital was extremely busy and
despite an agreed handover time of 15 mins, Mrs Conway waited in the ambulance for 2
hours and 50 mins. The longest waiting time on that date for a patient handover was one
minute short of five hours.

Whilst this delay alone did not result in her death, it did form a part of the cumulative
delays by which Mrs Conway was denied the best chance of having her knee infection
successfully treated and hence not going on to develop sepsis.

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. Evidence at the inquest indicated that discussions were taking place between
different departments within BCUHB with a view to agreeing a protocol to
establish an appropriate care pathway for patients presenting to the hospital
with an infected prosthesis, however nothing had been finalised regarding the
same.

2. Furthermore evidence indicated that although it was always intended that
antibiotics would be administered once the patient's knee had been aspirated,
there was a delay of almost two hours between this procedure and the
administration of antibiotics (a delay which was explained by being due to
“normal hospital procedures’).

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe your
organisations 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 21st October 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 following Interested
Person — (Daughters 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.

26 August 2016 [SIGNED BY CORONER]

Bwrdd lechyd Prifysgol

Bete! Cadwaladr

University Health Board Yebylty Gwynedd, Penrhosgarmedd, Bangor,
Gwynedd, LL57 2PW

Eln cyf/ Gur ref INC56087

PRIVATE & CONFIDENTIAL @» 01946 294104

Mir J Giitins Gofynnweh am / Ack tor:

HM Coroner North Wales Frace / Fax: 01248 385316

Wormey Ro 4 E-hogt / Emails ConcerneTear, bou@wales.nhe.uk
yng a sett . ach °

Ruthin, Denbighshire Bydedlad / Date: 24" October 2016

LLi5 1YN

Dear Mr Glitins

Re: Regulation 28 letter in respect of Pamela Conwy

Further to your Regulation 28 notifications to the Health Board following the inquest
of Pamela Conwy.

The Health Board has considered your concems in relation fo the following issues
outlined in the two notifications:

Elrst Regulation 28 Notification
Part 1 ~ That not withstanding changes which have been made by both BGUHB and

WAST, there remain wholly unacceptable delays with patiente belng kept waiting for
long periods in ambularices and ambulance resources consequences being
unavailable for allocation to other calls as a result of which the tisk of future deaths
continues

Part 2~ Evidence at the inquest indicated that the problem of patient flow in the
Maelor result In patlent delays within the Emergency Department and it is of
considerable concern te me that such probleme have been the subject of previous
regulation 28 reporis and are also within the scope of a number of ongoing inquests

Sesond Reaulation 28 Notification
Part 1 - Evidence at the inquest indicated that discuegione were taking place between

different deparirnente within BGUHB with a view fo agreeing a protesol to establish
en appropriate care pathway for patlents preeanting to the hospital with ani Infected
prosinesis, however nothing had been finalised regarding the same.

Part 2 - Furthermore evidence Indicated that although it was always intended that
antibiotics would be administered once the patient's knee had been aepirated, there
was a delay of almost two hours between this procedure and the administration of
anflibioties (a delay which was explained by being due to “normal hospital
procedures”

Gyfeliead Gohsblesth ar gyfer y Gadelrydd a'r Prif Welthredwr / Garreapondenes eddreze for Chelrman and Ghief Executive:
Swydaia'r Qwelihredwyr / Executives’ Ofilee,

Yeoyly Gwynedd, Penrhosgarmedd

Bangor, Gwynedd LLS7 2ew Gwefan: www.pbc.cymru.nhs.uk / Web: www.bou.wales.nhe.uk

Bwrdd techyd Prifysgol
Betsi Cadwaladr
University Health Board

Therefore please find enclosed two working action plans relating to this case. The
action plans will ba scrutinized by the Assistant Director or Nursing as well as the
Hospital Medical Director and will be monitored by the at the Quality and Safety
Group to ensure timely progress.

Yours sincerely

Mr Evan Modre
Executive Medical Director

Ene

Ymddiriedolaeth GIG '4 e. G IG

Gwasanaethau Ambiwlans Cymru CYMRL
Welsh Ambulance Services X J N H S
NHS Trust WALES

Pencadlys Rhanbarthol Ambiwlans a Chanolfan Cyfathrebu Clinigol
Regional Ambulance Headquarters and Clinical Contact Centre
Ty Vantage Point / Vantage Point House, TY Coch Way, Cwmbran NP44 7HF
Tel/Ff6n 01633 626262 Fax/Ffacs 01633 626299
www.ambulance.wales.nhs.uk

CHAIR AND CHIEF EXECUTIVE’S OFFICE

Our Ref: TM329/WH/ET
19 October 2016
PRIVATE AND CONFIDENTIAL

Mr John Gittins

HM Coroner

North Wales (East and Central Area)
County Hall

Wynnstay Road

Ruthin

LL15 1YN

Dear Mr Gittins

| am writing in response to your letter dated 26" August 2016 and the Regulation 28

Report to Prevent Future Deaths issued by your office following the inquest of Mrs

Pamela June Conway (Deceased). | would like to provide you with the assurance that

we have made progress against key actions which are all identified in the attached

action plan. | can confirm that the most significant impact is as a result of the Welsh

Health Circular (NHS Wales Hospital Handover Guidance) issued by PF
Director General of the NHS Wales, on 5 May 2016.

| can assure you that as a consequence of this case we have learned lessons as an
organisation which are being monitored through a Task and Finish Group of senior
staff, led by the Director of Quality, Safety and Patient Experience. | would also like
to assure you that the monitoring of the actions and agreed timescales will be
scrutinised through the Trust’s Quality, Patient Experience and Safety Committee.

Cadeirydd/Chair: — Mick Giannasi

Prif Weithredwr/Chief Executive: Tracy Myhill

Mae'r Ymddiriedoloeth yn croesawu gohebiaeth yn y Gymraeg neu'r Saesneg
The Trust welcomes correspondence in Welsh or English

Please do not hesitate to contact me if you have any questions with regards to the
action plan.

On a more general note, | look forward to meeting you and colleagues in your coronial
area to discuss areas of concerns to us all as we discussed in the Summer.

Yours sincerely

Fay yh

Tracy Myhill
Chief Executive

Enc.