Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0192, written 10 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jun 2019 |
|---|---|
| Reference | 2019-0192 |
| Deceased | Glenys Button |
| Coroner | Rachel Knight |
| Coroner area | South Wales Central |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
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ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Chief Executive, Cardiff and Vale University Health Board
Chief Executive, Cwm Taf Morgannwg University Health Board
Chief Executive, Swansea Bay University Health Board
Chief Executive, Powys Teaching Health Board
Chief Executive, Hwyel Dda University Health Board
Vaughan Gething, Health Minister, Welsh Assembly Government
CORONER
lam Rachel Knight, Assistant Coroner, for the coroner area of South Wales
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.
| AM SENDING THIS REPORT TO FIVE SEPARATE HEALTH BOARDS, BUT | WISH
TO RECEIVE A COLLABORATIVE SINGLE RESPONSE SETTING OUT A PROPOSAL
FOR A NEW SYSTEM OF REFERRALS. THIS PROPOSAL MUST BEST FIT ALL
BOARDS, SINCE THERE ARE A VAST NUMBER OF OUTLYING UNITS WHICH RELY
UPON ON NEUROLOGY AT UHW FOR ASSISTANCE.
A further response is also expected from the Welsh Assembly Government,
since there may be budgetary implications.
INVESTIGATION and INQUEST
On the 8" November 2018 an inquest was opened into the death of Glenys
Button. The investigation was concluded at a hearing on the 6" June 2019. The
conclusion was that Mrs Button had suffered an accidental death, following a
fall backwards onto a wooden floor at home.
CIRCUMSTANCES OF THE DEATH
Glenys Button was aged 78 on the 5'* November 2018 when she died at the
Royal Glamorgan Hospital. She had sustained a head injury involving a basal
skull fracture and an unusual pneumocephalus and brain bleed, fallowing a
likely accidental backwards fall onto a wooden floor at her home address on 2"4
November 2018. She had a number of co-morbidities including ischaemic heart
disease, diabetes, osteoarthritis and chronic obstructive pulmonary disease.
There is no neurosurgery ward at the Royal Glamorgan Hospital, therefore
trauma doctors there (and similarly in other outlying units throughout South
and West Wales) rely heavily upon emergency advice from the on-call
neurosurgeons at the University Hospital of Wales in Cardiff as to the treatment
and management of head and brain injury patients such as Mrs Button. It is the
neurosurgeons who make the final decision as to whether to transfer the
patient to the UHW for intervention.
In this case, there were frustrating delays in contacting the on-call neurosurgery
specialist registrar, there was confusion over whether Mrs Button was a suitable
candidate for transfer to the unit in Cardiff for treatment, there was conflict
over the discussion of her co-morbidities and there was inadequate written
evidence of the various conversations. Following a deterioration in her
condition, Mrs Button was firstly accepted, then rejected for transfer to Cardiff
{mid-journey) and was ultimately managed conservatively on a trauma and
orthopaedics ward at the RGH, where she succumbed to her devastating
injuries.
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) There are a high number of referrals to the single rota’d on-call
neurosurgical specialist registrar every day. The system for making and
receiving the referrals is not fit for purpose, with inefficient delays,
miscommunications and confusion occurring. The use of the UHW
switchboard and bleeping the doctor is archaic, and does not utilise
technology as it should. Further, if the on-call doctor is in surgery or
dealing with an emergency, there is no back up doctor to field the
referrals, which can often be time critical.
(2) There is a similar situation with spinal specialists, where Cardiff has the
experts and the outlying hospitals contact them for advice. A pro forma
document has been designed which is filled in by local doctors and sent
to a generic email address for the spinal team. The pro forma is
considered and completed by the specialists and emailed back with
answers. The only telephone call {to a direct number rather than the
switchboard) involves the outlying hospital notifying the spinal team to
expect an email referral. This system reduces the risk of delay and
miscommunication, and provides a single, collaborative document for a
patient’s notes. Could this be a better system to be used with
neurosurgery referrals as a short-term measure?
(3) There is a cutting-edge system used in Bristol, in Southmead Hospital,
called www.referapatient.org which uses modern technology to assist in
referring patients between departments/hospitals. The website is self-
explanatory. Could this be a better system to be used widely across the
NHS in Wales in the longer term?
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.
7 | YOUR RESPONSE
You are under a duty to respond to this report within 112 days of the date of
this report (double the usual response time, given the wide nature of this
report), namely by 30" September 2019. |, 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:
e the family of Mrs Button;
HR at the Royal Glamorgan Hospital;
HE 3 the Royal Glamorgan Hospital;
Hayhurst at the University Hospital of Wales; and
HR 2¢ Southmead Hospital
who may find it useful or of interest.
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.
10* June 2019 SIGNED:
nes
Rachel Knight
Assistant Coroner
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.
Your ref/eich cyf: Our ref/ein cyf: SL.DD Date/dyddiad:30th September, 2019. Tel/ffôn: 01443 443443 ext. 78131 Fax/ffacs: 02920 807854 Email/ebost: Mrs. R. Knight, Assistant Coroner, The Coroner’s Office The Old Courthouse Courthouse Street Pontypridd CF37 1JW Dear Mrs Knight, Re: Regulation 28 Report related to the death of Mrs Glenys Button On the 10th June 2019 you issued this report to 5 separate Health Boards and requested a collaborative single response proposing a new system of referrals into Neurology at UHW. As the issues specifically relate to the Neurosurgical Service which is commissioned by the Welsh Health Specialised Services Committee (WHSSC) the WHSS team was asked to coordinate that response. In addition, Aneurin Bevan University Health Board (UHB), which did not receive the Regulation 28 Report but who also commission Neurosurgical Services from Cardiff and Vale (C&V UHB), have been included in this process. A meeting was held on the 18th of July chaired by the Director of Nursing at C&VUHB which included management, clinical, patient safety team and IT representatives from C&VUHB as well as representatives from the patient’s Health Board of residence and the WHSS team. This group identified what they considered were the key issues and developed an action plan which was then considered by the Medical Directors of the six affected Health Boards. The summary below and the action plan reflects the input from the Medical Directors Group. Welsh Health Specialised Services Committee Unit G1, Main Avenue Treforest Pontypridd CF37 5YL Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru Uned G1, Main Avenue, Trefforest Pontypridd CF37 5YL Chair/Cadeirydd: Professor Vivienne Harpwood Managing Director of Specialised and Tertiary Services Commissioning/Rheolwr Gyfarwyddwr Comisiynu Gwasanaethau Arbenigol a Thrydyddol: Dr Sian Lewis A number of key points have been agreed which inform the action plan: 1. An electronic referral system offers significant advantages in that it allows clearer and more detailed communication between referring and receiving clinicians however for very urgent cases telephone contact is still required. This is because it is not possible to provide 24 hour monitoring of email or web based referral systems. 2. Mobile phone signal in hospitals can be patchy and therefore bleeps are always required. 3. The C&VUHB IT team had already developed an in house e-referral systems which appears to have better functionality compared with the currently available commercial system. The following action plan has been agreed for both paediatric and adult patients: 1. The current system for urgent and immediate care of patients with Emergency Neurosurgery needs will continue with the referral being made through the bleep system to the on call Neurosurgical Registrar. With effect from Monday 23rd September 2019 the referrer will be asked a question to gauge if the call is urgent or routine in nature. The urgency of the call will be communicated to the r Registrar via the bleep system which will enable them to prioritise urgent calls over less urgent tasks. If the Registrar is in theatre, there are arrangements in place to answer the bleep. Furthermore, if the Registrar cannot take the call, the referring team will be transferred back to switchboard for the on-call Neurosurgical Consultant to be contacted directly. 2. The on-call Neurosurgical Registrar will need to accept any emergency referrals and will ensure a clear plan is in place to manage the patient’s immediate care needs and to ensure effective communication with the referring team. Prior to the introduction of an e-referral system this will be followed up by an e–referral with a log of the call and the actions undertaken. 3. The new in house e-referral system will be piloted with Cwm Taf Morgannwg UHB starting at the beginning of August and a rigorous evaluation of the system built into the pilot from the outset. The evaluation will take place 3 months following the start of the pilot. Following agreement of this action plan we have been told by C&V UHB that the pilot has identified networking issues between C&V and CTM UHB and that this Welsh Health Specialised Services Committee Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru Uned G1, Main Avenue, Unit G1, Main Avenue Trefforest Treforest Pontypridd Pontypridd CF37 5YL CF37 5YL Chair/Cadeirydd: Professor Vivienne Harpwood Managing Director of Specialised and Tertiary Services Commissioning/Rheolwr Gyfarwyddwr Comisiynu Gwasanaethau Arbenigol a Thrydyddol: Dr Sian Lewis has prevented extension of the pilot study and these issues will need to be resolved before this can be rolled out further. The C&V UHB IT Development Team are working hard to resolve this issue as quickly as possible. In conclusion, whilst we had hoped to be able to confirm a date for roll out of an e-referral system this is not possible, but we have put in additional measures to avoid delays in making urgent referrals as well as an interim arrangement using email to improve communication around the referral process. In addition the team at C&V UHB are working hard to address the IT issues as soon as possible. I will forward a copy of the most up to date referral pathway when I receive it from C&V UHB. Please let me know if you require clarification or further information regarding these arrangements. Yours sincerely, Managing Director of Specialised & Tertiary Services Commissioning Welsh Health Specialised Services Committee Unit G1, Main Avenue Treforest Pontypridd CF37 5YL Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru Uned G1, Main Avenue, Trefforest Pontypridd CF37 5YL Chair/Cadeirydd: Professor Vivienne Harpwood Managing Director of Specialised and Tertiary Services Commissioning/Rheolwr Gyfarwyddwr Comisiynu Gwasanaethau Arbenigol a Thrydyddol: Dr Sian Lewis
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