Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0359, written 26 Oct 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Oct 2021 |
|---|---|
| Reference | 2021-0359 |
| Deceased | Kyle Hurst |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Suicide (from 2015) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
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 the27th of January 2021 I commenced an investigation into the death of Kyle Nicholas
James Hurst (DOB 8.7.91 DOD 24.1.21) The investigation concluded at the end of the inquest
on the 22nd of October 2021. The conclusion of the inquest was one of suicide with the cause of
death being 1(a) Multi Organ Failure
4
CIRCUMSTANCES OF THE DEATH
The circumstances of this death are that the deceased was admitted to Glan Clwyd Hospital on
the 24th of January 2021 after taking in excess of
treatment he passed away at the hospital later the same day.
. Despite receiving
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. Evidence given at the inquest by the ED Consultant indicated that it has been
recognised that the accelerated administration of N-Acetylcysteine may be beneficial in
the treatment of a
Standard Operating Protocol despite this having been proposed in August 2021
but this has not yet been adopted into a
2. Following the issue of a regulation 28 report on the 14th of July 2021 in connection with
the inquest touching upon the death of Rhian Roberts in similar circumstances, the
response from BCUHB indicated by way of a letter dated the 7th of September 2021 that
procedures to mitigate risks due to failure to act on diagnostic results would be approved
and active by the 1st of October 2021, however at the time of concluding the inquest of
Kyle Hurst on the 22nd of October, this had not been accomplished.
I am concerned that the Health Board continue to fail to achieve changes in a timely
manner, even in circumstances where they have set their own timeframe and that as a
result of this lives are being put at risk.
3.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
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
21st December 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 26th October 2021
Signature
Senior Coroner for North Wales (East and Central)
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
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.
Bloc 5, Llys Carlton, Parc Busnes Llanelwy,
Llanelwy, LL17 0JG
----------------------------------
Block 5, Carlton Court, St Asaph Business
Park, St Asaph, LL17 0JG
Dyddiad / Date: 11th January 2022
Mr John Gittins
Senior Coroner
North Wales (East and Central)
Coroner's Office
County Hall
Wynnstay Road
Ruthin
LL15 1YN
Dear Mr Gittins,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Kyle Nicholas James Hurst
I write in response to the Regulation 28 Report to Prevent of Future Deaths issued by
yourself to Betsi Cadwaladr University Health Board, following the inquest touching the
death of Kyle Hurst.
I would like to begin by offering my deepest condolences to the family and friends of Mr
Hurst, and I apologise for the concerns identified at the inquest that have given rise to
your notice.
The standard paracetamol antidote is N Acetylcysteine (NAC) given as an infusion. The
standard NAC infusion regime is given over 21 hours. There is however mounting
evidence that this can safely be given over a shorter period of time (12 hours) and this
accelerated regime is known as the SNAP protocol. The regimes relate to the way the
antidote is prescribed and given and the main benefit is of reduced length of stay with the
SNAP regime, it does not however mean initiating the antidote any sooner.
Although there is evidence accumulating that the accelerated regime is safe, and it is
being used by many UK hospitals now and it is referenced on TOXBASE guidance as an
option, it is still not officially sanctioned by the MHRA (Medicines & Healthcare products
Regulatory Authority). As such, any local adoption of the protocol requires each
organisation to locally review and authorise such actions. Within the Health Board, this
would be after careful local examination and consultation and formal approval at the
Drugs and Therapeutics Group.
At inquest, our witnesses gave evidence that across the Health Board we were working
to overhaul our paracetamol pathways and to include the SNAP protocol, and the SNAP
protocol was still going through the process of gaining approval.
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 updated protocol has been developed and was being formally approved at our Drugs
and Therapeutics Group in January. However, due to the unexpected wave of COVID
pressures arising from the Omicron variant and the redeployment of staff to vaccination
and front line services, this meeting has been cancelled. We therefore intend to take
executive decision to approve this procedure outside of the normal governance process
and this will be completed no later than the 31 January 2022. Once approved, we will
begin use of the protocol immediately.
In relation to the procedures to mitigate the risk of not acting upon diagnostic results, we
have developed a new Procedure for the Communication of Critical and Unexpected
Pathology Results. This document sets out the roles and responsibilities of staff and the
process to follow. This new procedure has been ratified.
We have had to strike a balance between expediting the implementation of new
procedures whilst ensuring proper governance, clinical engagement and the correct
implementation of any changes. However I hope the actions we are taking to ensure
special approval gives you confidence we will intervene where unacceptable delays
occur.
I am concerned to have heard from you that the Health Board has not on a number of
occasions met its own deadlines for improvement actions following serious incident
investigations. Whilst the COVID pandemic has undoubtedly impacted us greatly, I
accept this is not an acceptable position and we must improve.
In April 2021 we changed our serious incident process and this included all investigation
reports going for scrutiny and approval at an Incident Learning Panel. This new step in
the process adds an organisational level of scrutiny on all investigations completed by
our clinical divisions and we have seen an improvement in the quality of reports and
action plans as a result. We are also now tracking actions from these investigation reports
through our Datix patient safety system and auditing compliance with action completion
timeframes and evidence.
This process covers incidents from April 2021 onwards, and so for incidents prior to this
we have appointed a clinician to undertake a review of historic action plans to ensure
evidence is available against each action. This person commenced in post in November,
however they have been redeployed to front line services as a result of the current COVID
wave, and we hope they will be available to return back to this important work during
January 2022.
I hope my letter offers you assurance that we have worked to address the concerns, and
importantly that we have a new system in place to provide greater oversight and
assurance in the future.
One again, please may I offer my condolences to the loved ones of Mr Hurst and my
apologies for the concerns you have identified.
Should you require any further information or evidence of the actions outlined above
please contact either myself or Matthew Joyes, Associate Director of Quality Assurance.
Yours sincerely
Prif Weithredwr
Chief Executive
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