David Griffiths

Buvecicl lechyd Prifyseol
aerdvee ay Fra

Ca Me

adquariers
nd Vale Heath Park Pare ¥ Mynydd Bychan

{ University Health Baarel Cardiff, CFi4 axw Caerdydd, OF 14 4xW

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Gin cyi/Our ref:

Welsh Health Telephane Netyeorte:
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28" March 2017
Private and Confidential

Mr Philip Spinney

Area Coroner for South Wales Ceniral area
Coroner's Court

Central Police station

Cathays Park

Cardiff

CF10 38NN

Dear Mr Spinney,
Re: Regulation 28 report — David Robert Griffiths
Thank you for your letter dated 3" February 2017,

| have reviewed the concerns you've raised within the Regulation 28 report following
the inquest regarding the death of Mr Griffiths. My response has been informed by
senior clinical and managerial staff who are able to advise me on the arising
concems and pursue the improvements required as a result.

| recognise that this has been a particularly difficult time for Mr Griffiths’ family and |
would wish to offer them my sincere condolences on behalf of the University Health
Board.

You will be aware that the Health Board undertook an internal investigation following
the incident involving Mr Griffiths, which was reported to Welsh Government via the
Serious Incident reporting procedures in September 2016, Your concems arising
from the inquest align to the findings and recommendations made by the Consultant
in Intensive Care Medicine who investigated the incident.

For ease of reference, | have set out below the Health Board's response to the
issues you have raised.

e Consideration should be given to reviewing your procedures related to
chest drain insertion and consider Introducing an Induction programme
for all new medical and nursing staff.

The UHB has considered the findings of the investigation and has taken the

decision to discontinue the practice of inserting chest drains at a ‘marked gst Mag,
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spot’ and is introducing a revised procedure whereby chest draing are
inserted under direct vision ultrasound guidance, This was confirmed by the
Clinical Director of Radiology and communicated to key senlor medical staff
across the UHB tn early January 2047,

tn addition to this, additional support from the Respiratory on-call team has
been made available in the in-hours scenario for doctors who require support
and are not appropriately accredited. On the rare occasion that an out of
hours pleural aspiration or drain insertion Is required (e.g. for suspected
pleural Infection, significant symptomatic or haemodynamic compromise) tt
has been agreed that the on call medical team should be contacted

A working group has been established with a specific remit to improve the
safety of patients undergoing intercostal chest drain insertion and to ensure
the Health Board’s compliance with the related British Thoracic Society
guidance (Reference: Havelock T, Teoh R, Laws D, Gleeson F. Pleural procedures
and Thoracte Ultrasound: British Thoracic Society Pleural Disease Guideline 2010.
Thorax; 65(suppl 2)1161-1176),

There Is representation from the Clinical Boards an tadiology to consider
several issues and it Is being chaired __!| respiratory
Physician.

The use of Ultra sound guidance
The training of staff to use these in and out of hours
Training in chest drain insertion

This group will also consider the requirement for specific induction in relation
to chest drain insertion, on the basis, that registrars and specialist registrars
across specific specialities are employed on the basis, that they are already
competent in a number of core and essential skills, which would Include chest
drain Insertion. The UHB Is currently liaising with the Welsh Deanery on this
issue

In relation to general Induction programmes for all new medical and nursing
staff, the Workforce and Organisational Development Department has
procedures in place to assist managers to ensure the appropriate induction of
new staff members to an individual department and wider organisation.

Staff members are allocated a day to attend a corporate induction programme
for organisational induction. They receive a letter of Invitation and managers
are required to release staff to attend,

Senior medical staff are offered an opportunity to attend a Senior Medical
Staff Induction programme which is coordinated by the Learning, Education
and Development Department in conjunction with the Medical Workforce
Department.

The Health Board recognises the importance of local induction to individual
departments in order to support new employees. A local induction checklist is
available io support managers and new staff in the induction process. O80,

Please address sorespondence to: Chisel Executive's Office, Candiif and Vale University Health Board,
University Hogplial of Welog, Hoath Pent, Gaedif CFL axy

information about induction procedures is available on the Health Board's
web site which can be accessed via the link below:

ahs.

It is recognised that requirements for the content of local induction will vary
significantly across the many depariments within the Health Board. For
medical staff, local induction processes are overseen by the relevant
Directorate's Clinical Director; by senior Directorate nursing staff for new
nurse employees and so forth, depending on the staff discipline.

My response to the concems that you have raised will be shared with all
Clinical Boards with a request that they seek assurance from their
Directorates that appropriate induction processes are in place across the
Health Board.

Consideration should be given to the acquisition of appropriate
ultrasound equipment to allow real time guidance of chest drain
insertion, pleural procedures and diagnostics,

J am pleased to be able to advise you Consultant
Physician and Respiratory Lead has also coordina ied the purchase of two
additional ultrasound machines suitable for use in these clinical
circumstances. The purchase has been supported by the Health Board's

Medical Equipment Group and Procurement Department.

Consideration should be given to an ultrasound training programme
and governance structure for all practitioners who are responsible for
the insertion of intercostal drains,

It is of paramount importance that staff are appropriately trained to insert
intercostal drains using the ultrasound equipment that has been purchased.

A bespoke thoracic ultrasound training course was provided to the
Cardiothoracic Directorate on 16" March 2017 with support from
Davies and the manufacturer of the purchased equipment.

it is recognised that afrangements for ongoing training and competence
assessment must be in place across the Health Board and this will be
implemented and overseen by the task and finish group.

. The group will report to the Quality, Safety and Experience Committee
which receives information regarding Regulation 28 - Prevention of Future
Deaths Reports in order to ensura the necessary progress is being made,

Additionally, the Welsh Goverment issued a Patient Safety Notice PSNO34
‘Supporting the introduction of the National Safety Standards for Invasive
Procedures’ in September 2016. Welsh NHS organisations are required to

complete the necessary actions on this safety notice by September 2017, ae Mog

The notice can be accessed via the website link which Is provided here for
your reference:

A similar safety notice was published in NHS England in September 2015.
Resources are therefore developed for use in NHS England that can be
adapted and adopted for use in NHS Wales. The task and finish group
intends to explore the implementation of a safety checklist for chest drain
insertion. An example of such a tool, developed by the Intensive Gare
Society, is attached In Appendix 1.

| hope that the information set out in this letter provides you with the assurance that
the Health Board has fully considered the Issues raised as a consequence of the
investigation, Inquest and your letter of 3 February 2017, and has taken appropriate
action In response,

Yours sincerely

Interim Chief Executive

Please address corespondenne to: Chisf Executlye’s Offices, Cardiff and Vale Universily Health Board, " _
University Hogpltal of Wales, Heatls Park, Gerdlff CE4d anit