Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0029, written 10 Feb 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Feb 2017 |
|---|---|
| Reference | 2017-0029 |
| Deceased | Raymond Edwards |
| Coroner | Nicola Jones |
| Coroner area | North Wales (Eastern 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. CHIEF EXECUTIVE BETSI CADWALADR UNIVERSITY HEALTH BOARD 1 | CORONER lam Nicola Jones, assistant coroner, for the coroner area of North Wales (Eastern 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 14 November 2016 | commenced an investigation into the death of Mr Raymond Edwards, aged 69. The investigation concluded at the end of the inquest on 23 January 2017. The conclusion of the inquest was: NARRATIVE CONCLUSION- On 24 November 2015 Mr Raymond Edwards was operated for Terminal lleum. He developed an anastomatic leak which was operated on 1 December 2015 but Mr Edwards died from sepsis and multi organ failure on 2 December 2015 at Ysbyty Glan Clwyd. 4 | CIRCUMSTANCES OF THE DEATH Mr Raymond Edwards was initially admitted to Glan Clwyd Hospital on 17 June 2015 and underwent a laparotomy for ischaemic bowel secondary to small bowel volvulus. He was discharged on 2 July 2015. Histology of the excised bowel was undertaken and revealed the rare disease amyloidosis. This histology result was never received by the named consultant and the disease was not followed up. Mr Edwards was re admitted to Glan Clwyd Hospital on 13 November 2015 after feeling generally unwell. On 24 November 2015 Mr Edwards was operated upon and his appendix removed and a small area of ischaemic bowel excised and a primary anastomosis. By the date of this operation the relevant department were aware of the amilioidosis. By 1 December 2015 Mr Edwards’ condition rapidly deteriorated suggestive of an anastomotic leak. This was operated on 1 December2015 but Mr Edwards continued to deteriorate and died on 2 December 2015. The medical cause of death was 1a. Multi Organ Failure, Sepsis 1b. Anastomotic Leak (Operated 1 December 2015), 1c. Ischaemic Terminal lleum (operated 24/11/2015). Il. Pulmonary Embolism (warfarinised), Rheumatoid Arthritis (on Methotrexate), Laparotomy for Ischaemic Small Bowel secondary to small bowel volvulus (operated 17/06/2015), Amiloidosis. 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. !n 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) During the Inquest it became clear that there is no reliable system or protocol for the dissemination of histology results to the named consultant for a patient. In this case the consultant for Mr Edwards informed the inquest that the histology result had gone to the file of Mr Edwards as he had been discharged. He did not chase the result as the operation passed without incident. The Consultant informed the court that had he had the result of histology showing amiloidosis that he would immediately have referred the patient on for urgent investigation of this serious condition. Having had these results at an early stage would have informed the treatment for Mr Edwards subsequently. The fact that this information was not passed in a timely fashion did not cause or contribute to the death of Mr Edwards. However, it is clear that unless there is a clear system for bringing histology results to the attention of a named Consultant that there could be a death in future. The consultant himself identified a need for a more robust system of delivering histology reports to consultants. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you AND your organisation 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 7 April 2017. |, 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 Persons -CHIEF EXECUTIVE BETS] CADWALADR UNIVERSITY HEALTH BOARD - GAMLINS LAW, SOLICITORS FOR NEXT OF KIN | 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 resp by the Chief Coroner. [DATE] 10 February 2017 [SIGNED BY/C! RO ER] N Jones
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.
f. aN GIG | ewraa lechyd Prifysgol Block 5, Carlton Court St Asaph Business Park “Lj CYMRU | Betsi Cadwaladr St Asaph 97 H University Health Board Denbighshire WALES LL17 0JG Mr John Gittins Ein cyf / Our ref: EM/dw HM Senior Coroner for North Wales (East —Ejgh cyf / Your ref: and Central) @: 01248 385139 County Hall Wynnstay Road Gofynnwch am / Ask for: is Ruthin E-bost / Email: Denbighshire Dyddiad / Date: 3° May 2017 LL15 1YN wee ¥ Dear Mr Gittins Re: System and Protocol for Dissemination of Histology Results | write in response to the Regulation 28 of 10 February 2017 highlighting the concern that there is no reliable system or protocol for the dissemination of histology results to the named Consultant for a patient. As a result of cases where failure to act on findings caused delays in patient treatment a series of meetings were arranged to review current practice and establish consistent and robust systems for disseminating results following examinations and tests. Work was undertaken to develop BCUHB Procedure MD23 ‘Procedure to mitigate the risks due to failure to act on diagnostic results’ based on NPSA 16 guidance. This procedure was approved at the end of 2016 and a copy is in the action plan. Itis the ultimate responsibility of the health professional ordering the investigation to follow up the results and to act on them. This has been facilitated by the histology reports being sent to the requesting clinician and not the clinical location of the procedure. However paper histology reports may not reach their intended destination and for this reason all histology reports are also made available to the named Consultant on the Welsh Clinical Portal (WCP). To strengthen this process an electronic reporting system with a function to alert the requesting clinician when histology reports are authorised for viewing needs to be made available. Work has begun to develop the CHAI Ping app to provide the solution to the current gap in the WCP of ‘notification’ that a result is available and ‘authorise and recording of action taken’. This would work with the WCP to enable the organisation to improve assurance and stop printing reports for the results in scope i.e. those available to view in the WCP. The Health Board accepts that the current procedure for the dissemination of histology results can be improved. | hope this letter and action plan offers the required level of assurance that we are focused on taking action to address the issues raised in your letter. Please let me know if you would like further detail on any of the areas within my response. Yours sincerely Evan Moore Cyfarwyddwr Meddygol Gweithredol a Dirprwy Brif Weithredwr Executive Medical Director and Deputy Chief Executive Enc: Action Plan
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