Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0375, written 9 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Nov 2021 |
|---|---|
| Reference | 2021-0375 |
| Deceased | Susan Merton |
| Coroner | John Gittins |
| Coroner area | North Wales (East and 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 |
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 the 23rd of August 2019 I commenced an investigation into the death of Susan Merton (DOB 1.3.54 DOD 23.8.19) The investigation concluded at the end of the inquest on the 5th of November 2021. The conclusion of the inquest was one of a death arising from natural causes with the cause of death being 1(a) Sepsis (b) Extrahepatic Biliary Obstructions, Pancreatitis (c) Common Bile Duct Stone 2. Hypertensive Heart Disease 4 CIRCUMSTANCES OF THE DEATH The circumstances of this death are that the deceased had undergone a CT scan, the reporting of which failed to identify the presence of a common bile duct stone. When this was later recognised and appropriate treatment was scheduled to take place, the deceased’s condition suddenly deteriorated acutely and she passed away at Glan Clwyd Hospital on the 23rd of August 2019. 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 provided to me in the course of the investigation indicated that the Health Board had conducted an investigation and had produced an Action Plan in light of the f indings of that investigation. The Action Plan required that the recommendations contained therein be reviewed in a Clinical Governance Meeting on the 5th of August 2021 however f or reasons which could not be explained at the inquest, this was not done. 2. On previous occasions I have issued regulation 28 reports expressing concerns that the Health Board continually fail to accomplish actions in circumstances where they have set their own timeframe. I am concerned that as a result of the Health Board failing to follow through with their own actions and recommendations either in a timely manner or in this specific case at all, lives are being put at risk. 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 28th of 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 9th November 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
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
Susan Merton
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 Susan Merton.
I would like to begin by offering my deepest condolences to the family and friends of Ms
Merton, and I apologise for the concerns identified at the inquest that have given rise to
your notice. I also apologise that this is the second notice you have issued in regards to
the completion of actions following serious incident investigations.
I would like to assure you that direct conversations have been held with the responsible
service and we are providing close oversight of quality and safety in that area.
As outlined in my response to the Regulation 28 regarding Mr Hurst, we changed our
serious incident process in April 2021. From this date all investigation reports are
submitted 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. A report without an action plan would not be accepted. I am very
disappointed that our service did not complete an action plan when they should have
done, nor was it completed on the right template when it was. Our new process ensures
this cannot happen.
We are also now tracking actions from these investigation reports and action plans
through our Datix patient safety system and auditing compliance with action completion
timeframes and evidence.
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
This new process covers incidents from April 2021 onwards. We recognise the case of
Ms Merton, and Mr Hurst, occurred prior to this, so we have appointed a clinician to
undertake a review of historic action plans to ensure actions are completed and evidence
is available. This person commenced in post in November 2021, 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. This work
will continue until we are assured of prior action plan completion.
I hope this letter offers you assurance that we have implemented a new system to
address the concerns and provide greater oversight and assurance in the future. I also
hope that our work to review action plans prior to the new process also offers assurance
to you.
One again, please may I offer my condolences to the loved ones of Ms Hurst and my
apologies for the concerns you have identified on this and other occasions.
Should you require any further information or evidence of the actions outlined above
, Associate Director of Quality Assurance.
please contact either myself or
Yours sincerely
Prif Weithredwr
Chief Executive
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.