Brian Wareham

>> NHS  University Health Board 

Bwrdd lechyd Prifysgol 
Aneurin Bevan

Ms Caroline Saunders 
HM Senior Coroner for Gwent 
Room 204W 
The Civic Centre 
Godfrey Road 
Newport 
NP20 4UR 

Dear Ms Saunders 

21 February 2022 

u 

Re: Aneurin Bevan University Hea.Ith.Board response to Regulation 28 
Report received following the inquest touching on the death of 
Mr Brian Wareham. 

Thank you for your report dated 14 January 2022, which was received by the 
Health Board on 19 January 2022. We have conducted a review of this case, 
which has included a review of Primary and Secondary Care clinical records. 
This response is based on information from this review, provided by Dr 

, Primary Care Clinical Director. 

Further to your report, the information presented below is intended to describe 
the action taken/being taken by the Aneurin Bevan University Health Board 
(ABUHB) to mitigate the risk of future deaths. 

Mr Wareham's case, as is illustrated by the statements provided to yourself 
prior to the inquest, was complex and required involvement of multiple 
professionals. In addition to this he had two significant medical conditions 
(oesophageal dysmotility and small cell cancer of the lung) which were difficult 
to diagnose and where the treatment options were limited. Specifically, there 
were no curative treatment options that were deemed suitable by the treating 
specialists. The experience of Mr Wareham and his family demonstrates the 
challenges and difficulties of coordinating care between different Specialist 
teams, Hospital sites and Care settings. 

Pencadlys 
Ysbyty Sant Cadog 
Ffordd Y Lodj 
Caerllion 
Casnewydd 
De Cymru NP18 3XQ 

Headquarters
St Cadoc's Hospital
Lodge Road
Caerleon 
Newport 
South Wales NP18 3XQ 

Bwrdd lechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd lechyd Prifysgol Aneurin Bevan 
Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Health Board 

 
 
	
	
	
	
	
	
	
 
 
 
 
 Ms Caroline Saunders 

2 

21 February 2022 

 during his evidence. Dr J

Such situations can be particularly challenging for Primary Care, as highlighted 
has discussed Mr Wareham's care 
by Dr 
with Dr 
 and the concerns that this case highlighted. With the benefit of 
access to the full medical records, it was apparent that the Gastroenterologist, 
Dr 
 by email to give a detailed summary of 
Mr Wareham's swallowing issues and the plan of care. This email was included 
in the main GP clinical record. Also, a detailed letter regarding the diagnosis of 
small cell cancer and the management plan was sent to the Practice by Dr 

, had contacted Dr 

. This included the names of key worker contacts (Lung Cancer Specialist 
Nurses), which is a Welsh Government recommendation for all individuals who 
are diagnosed with cancer. Mr Wareham remained under the care of Dietitians 
and regular written updates and prescription recommendations were sent to 
the Practice. He was also referred to Speech and Language Therapy by the GP 
Practice. 

For individuals in the community, the registered GP has overall responsibility 
for their medical care. The Primary Care team will therefore be the first point 
of contact for most health issues, and will take the role of coordinators in a 
patient's health care management. However, we acknowledge that in these 
situations it can be difficult for Primary Care teams to ascertain who is the 
most appropriate single point of contact when needing support to care for 
individuals who have multiple complex health issues. Due to specialisation in 
hospital medicine, there may not be a single point of contact which requires 
Primary Care teams to be a point of continuity and coordination. There are 
multiple ways in which Primary Care teams can obtain information regarding 
an individual's hospital care. In the Gwent area, GPs have access to the 
Clinical Workstation (CWS) system where all clinic letters and hospital records 
are stored. This enables a GP to review records and past/future appointments 
to ascertain which hospital clinicians are involved in an individual's care. Clinic 
and Discharge letters would usually also be sent directly to a GP Practice, 
which will include the name of the responsible consultant and contact details 
for the secretary. Contact details for hospital based clinicians can be obtained 
through hospital telephony switchboards or via the NHS email address book, 
which is available to GPs. These sources of information and support would 
have been available to Dr 
Wareham's GP Practice received communication from Gastroenterology, 
Respiratory Medicine, Dietitians, Speech and Language Therapy, and Cancer 
Nurse Specialists. It is apparent from the GP clinical records that once Mr 
Wareham was referred to St David's Foundation Community team, the 
Palliative Care Nurse fulfilled the role of care coordinator in the community and 
single point of contact. 

 when delivering care to Mr Wareham. Mr 

On discussing the issues of communication with Secondary Care with Dr 

, he pinpoints telephone communication as a key method which is often 

helpful but rarely possible in practice, whilst acknowledging that it is very 
difficult for hospital specialists to contact GPs by telephone in a timely manner. 

	
	
 
 Ms Caroline Saunders 

3 

21 February 2022 

Due to work patterns and pressures of work, which would have been a 
particular issue in 2020 during the early stages of the Covid 19 pandemic, 
synchronous communication between Primary Care and hospital specialists (eg 
by telephone) is difficult to facilitate. Dr D
expressed the view that he did 
not seek further direct advice from hospital specialists regarding Mr Wareham 
following his admission in June 2020, as it appeared evident from the hospital 
records that they did not feel further specialist interventions were appropriate 
or possible. However, we note that Mr Wareham continued to have follow up 
with the Dietitian and the Lung Cancer CNS and the Practice referred him for 
assessment with Speech and Language Therapy. The outcomes of these 
reviews were communicated to the GP Practice. 

Since 2020, major changes have taken place within ABUHB boundary due to 
Covid 19, but also due to the reorganisation of our Services and the opening of 
the Grange University Hospital. These changes have required us to develop 
methods and strategies to enhance communication at the interface between 
Primary and Secondary care. Some of the main changes we have made 
include: 

•  Establishment of a single point of access Flow Centre for urgent 

referrals for admission. 

•  The Flow Centre line includes the option to speak to a Medical 

Consultant for clinical advice. 

•  Launch of direct access telephone advice lines for urgent and outpatient 

queries using the "Consultant Connect" advice and guidance app. 
•  A directory of "bypass numbers" to allow hospital teams to contact GP 

surgeries directly when there is an immediate need. 

As you will be aware, the Medical Examiner (ME) Service is now operating in 
Gwent with cases referred by the ME being reviewed by a Multidisciplinary 
Panel, which includes Primary Care input. This provides us with a further 
mechanism to identify and review any issues regarding the interface between 
Primary and Secondary care. 

We also send all GPs a weekly message from the Deputy Medical Director, 
highlighting key information and any changes to Secondary Care Services to 
ensure Primary Care remain up to date on how to access and communicate 
with Specialist Services. Information on pathways, Secondary Care Services 
and advice lines is also obtainable on the ABUHB intranet, which is accessible 
to GPs through the NHS computer network. As part of our urgent care and 
outpatient transformation work streams, we aim to keep these resources up to 
date as Services evolve. 

	
	
 Ms Caroline Saunders 

4 

21 February 2022 

I trust that this information addresses the concerns raised in your report, 
however please do not hesitate to contact me should you require any further 
information. 

Yours sincerely 

Prif Weithredwr dros dro/Interim Chief Executive

TIDE RICHMOND. CL,INIC 
172 Caerleon Road, Newport, Gwent NP 19 7FY 
TEL: 01633 259970 FAX: 01633 221210 

MAR  ?1,12 

21St February .2022 

Ms Caroline Saunders 
Senior Coroner for Gwent 
Gwent Coroner Services 
Civic Centre 
Godfrey Road 
Newport 
Gwent 
NP20 4UR 

Dear Ms Saunders 

I am writing to you in response to the Regulation 28 report you sent me regarding the 
death of Mr Brian Wareham dated 14th January 2022. 

section (6) — "Action should be taken", I can confirm that this matter has been 

As 
investigated within the practice. In addition, following a meeting between Dr 

 and representatives of the Health Board on 2nd February 2022, we 
~.;nderstand a further process is continuing within the Health Board, with which we 
are cooperating fully. As part of this process we have fully explored all current 
options and opportunities for communication between Primary and Secondary Care 
and have ensured that all clinical staff are aware of them. In particular we have 
explored specific obstacles to communication within this case and addressed them. 
We understand that there is an ongoing programme within the Health Board to 
further facilitate communication between primary and Secondary Care and we are 
engaging positively with that work. 

I hope this response provides you with the information requested. 

Yours sincerely 

Dr 
Senior Partner 

Drs 

, Dr 

, Dr 

 & Dr