Prevention of Future Deaths reports · 2021

Rhian Roberts

Regulation 28 report to prevent future deaths, reference 2021-0242, written 14 Jul 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report14 Jul 2021
Reference2021-0242
DeceasedRhian Roberts
CoronerJohn Gittins
Coroner areaNorth Wales (East and Central)
CategoryHospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards)
Sourcejudiciary.uk record · original PDF
Responses publishednone published

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Betsi Cadwaladr University Health Board 
Corporate Offices 
Block 5, Carlton Court 
St Asaph Business Park 
St Asaph, Denbighshire LL17 0JG 

Ein cyf / Our ref: 
Eich cyf / Your ref:  
: 
Ffacs / Fax: 
E-bost / Email:
Dyddiad / Date: 

7 September 2021

Mr John Gittins 
Coroner  
HM Coroner’s Office 
County Hall 
Wynnstay Road 
Ruthin 
LL15 1YN 

Dear Mr Gittins 

Re. Regulation 28 issued in relation to the death of Mrs Rhian Margaret Roberts 
(D.O.B 06.08.1970 D.O.D 25.11.2020) 

Further to the Regulation 28 issued by yourself on the 14th July 2021 in relation to the death 
of the above named patient, please find below the Health Board’s response to your matters 
of concern.  

1. On  arrival  at  ICU  the  clerking-in  doctor  requested  a  toxicology  screen  to  include
paracetamol  and  salicylate  levels  (notwithstanding  that  blood  tests  to  include  this
were already in hand) and there was no evidence available at the inquest to establish
whether or not the toxicology screen requested by the doctor was undertaken and if
not why not.

The  request  for  the  toxicology  screen  to  include  paracetamol  and  salicylate  levels 
was documented in the doctor’s clerking proforma but this was not undertaken. The 
usual  admission  blood  tests,  (full  blood  count,  urea  and  electrolytes,  coagulation 
screen), were undertaken but not the additional tests that were documented in the 
management  plan. We  have  been  unable  to  establish  why  this  did  not  happen  as 
usual  practice  would  be  that  the  doctor  would  verbally  communicate  to  the  Nurse 
looking after the patient if any additional investigations were required.  

Following this incident, it was added to the Intensive Care Unit (ITU) safety brief for 
2 weeks that the doctors must verbally communicate anything specific required. The 
Nurses have also been informed that they must check the management plans if they 
have  been  away  from  their  patient  e.g.  for  a  break,  as  an  additional  measure  to 
reduce the risk of missing something that has occurred in their absence. 

2. An  internal  investigation  by  the  health  board  following  Mrs  Roberts’  death  rightly
established  that  action  needed  to  be  taken  to  update  or  modify  the  SOP  for
communicating  of  life-threatening  blood  results  directly  with  clinical  areas  and  an
action plan indicated that this would be completed by the 30th of June 2021. At the
time of the inquest on the 13th of July, the proposed update remained in draft form
only and had not yet been approved.

The  Standard  Operating  Procedure  (SOP) for  telephoning  reports  and  results  was 
updated, approved and active as of the 20th July 2021 and discussed in the team brief 
meeting. 

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: 
Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW

Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk 

 
 An  annual  audit  is  undertaken  on  the  telephoning  of  results,  which  monitors 
compliance with phone log record keeping. Historically we have only asked for staff 
to record the name of the person taking the results, however following this incident 
we will mandate that staff record the name and role of the individual taking the results. 

In  addition  to  this,  the  current  procedure  to  mitigate  risks  due  to  failure  to  act  on 
diagnostic results (MD23) has been discussed in the ‘Results Management Project 
Board’ chaired by the Interim Secondary Care Medical Director Dr Gary Francis. The 
project board are reviewing the procedure with a timescale to be updated as required, 
approved and active by the 1st October 2021. 

A business case for a desktop application and dashboard has also been approved in 
principle to improve the assurance for the management of results across the Health 
Board.  This  is  a  key  development  to  enable  us  to  safely  rely  on  notifications  and 
electronically  sign  off  results.  Results management  will  be  delivered  alongside  the 
Digital  Health  Records  project  under  the  Patient  Record  Transition  Programme, 
which grounds itself in the space of improving patient care through the safe transition 
from paper to digital reports. 

3.  I am concerned that the continual delays in investigating adverse incidents, sharing 
learning and implementing actions following the same, create risks to patient safety. 

A  new  process  to  support  the  services  to  deliver  timely  investigations  was 
commenced  in  April  2021.  This  process  will  improve  performance  and  ensure 
investigations are robust, proportionate and timely.   

A daily review panel is led by the Corporate Patient Safety Team and attended by 
governance leads from across the Health Board. All level 3-5 incidents (moderate, 
major  and  catastrophic  severity)  are  reviewed  to  determine  which  are  classed  as 
serious incidents in line with the national Serious Incident Framework. This panel will 
commission serious incident reviews (SIRs) and determine the appropriate level of 
complexity  of  investigation  and  level  of  objectivity.  An  investigating  officer  is 
appointed alongside a Senior Reviewer  who provides direction to the investigation 
whilst supporting and directing the investigating officer role. 

A  weekly  executive  panel  scrutinise  and  confirm  or  amend  decisions  made  at  the 
daily panel to ensure direct executive oversight. This executive panel is led by the 
Executive Director of Nursing and Midwifery and Executive Medical Director.  In the 
event  a  particularly  serious  or  notable  incident  occurs,  a  Rapid  Serious  Incident 
Learning Panel is held within 24 hours. This panel will be led by a clinical executive 
and it is expected that senior divisional representatives and the clinical leads for the 
service will attend to agree on the immediate steps being taken to ensure safety and 
learning across the organisation and to discuss any immediate support. These panels 
are opportunities to reflect and learn and to ensure any immediate steps are taken to 
prevent a similar incident and to ensure staff who may be affected are also supported 

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: 
Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW

Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The involvement of patients or their families will be strengthened. It is expected that 
the  investigator  and  senior  reviewer  contact  the  patient  or  family  at  the 
commencement of an investigation to agree the terms of reference, agree their level 
of involvement in the investigation and how they wish the findings to be presented. 

Depending  on  the  complexity  of  the  incident,  investigations  are  required  to  be 
completed  within  25  to  45  working  days.   Any  extensions  must  be  requested  in 
advance  from  the  Associate  Director  of  Quality  Assurance.  The  progress  of  the 
investigation  is  tracked  via  a  weekly  governance  report  that  is  scrutinised  in 
directorate weekly governance meetings.  

Once  complete,  local  scrutiny  of  the  investigation  report  is  undertaken  to  ensure 
factual accuracy, thoroughness of the investigation, quality of the report and approval 
of  the  action  plan.  Once  this  local  sign  off  is  completed,  the  report  will  then  be 
reviewed and scrutinised at an organisational Incident Learning Panel. 

All actions arising from a serious incident investigation will be uploaded to the Datix 
incident system on final approval of the investigation by the Corporate Patient Safety 
Team. Services will upload evidence of completion when closing actions. The timely 
closure of actions will become a performance measure and audits will take place of 
submitted evidence to ensure quality and learning.  

Finally, we are strengthening the sharing of learning by developing a learning portal, 
lessons on a page, digital sharing of learning and a monthly lessons learned event. 
To support the new processes, a comprehensive training passport is being finalised. 
This passport consists of modular courses to develop skills as an investigating officer 
or  senior  reviewer.  A  mentor  scheme,  drop  in  support  sessions  and  an  ongoing 
community of practice will also be launched. The application of human factors skills 
will be a key element of this training.  

This  new  process  underpins  the  fundamental  principles  we  wish  to  establish  for 
serious  incidents:  the  active  involvement  of  those  affected  (patients,  families  and 
staff) in the investigation, the timely completion of high quality investigations and the 
implementation of meaningful improvements. 

If you require any further information or wish to discuss this, please do not hesitate to contact 
me. 

Yours sincerely 

Dirprwy Prif Weithredwr 
Deputy Chief Executive 

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: 
Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW

Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk
Also filed under 2021-0242: Rhian-Roberts-2021-0242.pdf
John Adrian Gittins 
Senior Coroner for North Wales (East and Central) 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO:  BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, 

Gwynedd LL57 2PW 
CORONER 

1 

I am John Adrian Gittins, Senior Coroner for North Wales (East and Central)                     

2 

CORONER’S LEGAL POWERS 

I 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 the1st of December 2020 I commenced an investigation into the death of Rhian Margaret 
Roberts (DOB 6.8.70 DOD 25.11.20) The investigation concluded at the end of the inquest on 
the 13th of July 2021. The conclusion of the inquest was one of misadventure with the cause of 
death being 1(a) Multi Organ Failure (b) Paracetamol Toxicty 

4 

CIRCUMSTANCES OF THE DEATH 

The circumstances of Mrs Roberts’s death are that she was admitted to Glan Clwyd Hospital on 
the morning of the 22nd of November 2020 after being found unresponsive at home as a result of 
a presumed overdose. 

Tests undertaken on admission to hospital established that she had extremely high levels of 
paracetamol in her system and although these results were available on the portal at 11.57, the 
treating clinicians in ICU did not become aware of this until the early hours of the following 
morning, when action was then taken by the administration of N-Acetylcysteine. Despite this 
treatment she continued to decline and passed away on the 25th of November 2020. 

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.  On arrival at ICU the clerking-in doctor requested a toxicology screen to include 

paracetamol and salicylate levels (notwithstanding that blood tests to include this were 
already in hand) and there was no evidence available at the inquest to establish whether 
or not the toxicology screen requested by the doctor was undertaken and if not why not. 

2.  An internal investigation by the health board following Mrs Roberts’ death rightly 
established that action needed to be taken to update or modify the SOP for 
communicating of life-threatening blood results directly with clinical areas and an action 
plan indicated that this would be completed by the 30th of June 2021. At the time of the 
inquest on the 13th of July, the proposed update remained in draft form only and had not 
yet been approved.  
I am concerned that the continual delays in investigating adverse incidents, sharing 
learning and implementing actions following the same, create risks to patient safety. 

3. 

Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN 
Tel 01824 708047    |    Fax 01824 708048 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you have the power 
to take such action. 

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 
8th of September 2021 I, 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. 

I 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. 

9 

Dated 14th July 2021 

Signature 

Senior Coroner for North Wales (East and Central) 

Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN 
Tel 01824 708047    |    Fax 01824 708048

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