Prevention of Future Deaths reports · 2019

Glenys Button

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 report10 Jun 2019
Reference2019-0192
DeceasedGlenys Button
CoronerRachel Knight
Coroner areaSouth Wales Central
CategoryHospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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.

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

Responses

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.

Response from NHS Wales (PDF)
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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