Prevention of Future Deaths reports · 2022

Trevor Reynolds

Regulation 28 report to prevent future deaths, reference 2022-0132, written 6 May 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report6 May 2022
Reference2022-0132
DeceasedTrevor Reynolds
CoronerJohn Gittins
Coroner areaNorth Wales (East and Central)
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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 25th of  May 2021 I commenced an investigation into the death of Trevor Reynolds (DOB 
14.4.42 DOD 15.5.21). The investigation concluded at the end of the inquest on the 4th of May  
2022.  The conclusion of the inquest was a narrative in the following terms : 

“On the 3rd of  May 2021, Mr Trevor Reynolds had a CT scan at Glan Clwyd Hospital, the 
purpose of which was to establish the effectiveness of treatment which he had been having for 
cancer of the oesophagus. On the 6th of May this was reported by a radiologist as incidentally 
revealing a clot on the lungs, a result which needed to be brought to the immediate attention of 
the ref erring clinician so that remedial treatment could be started. For reasons associated with 
working practices at that time the result of this scan was not acted upon until it was identified by 
Mr Reynold’s GP on the 10th of May and he was immediately admitted to hospital where 
treatment was commenced. 

Despite appropriate treatment being undertaken over the course of the next few days, Mr 
Reynolds passed away at Glan Clwyd Hospital on the 15th of May 2021 with a subsequent 
examination establishing that he had died as a result of both the pulmonary emboli and a 
pneumonia.  

The evidence indicated that had treatment for the clot began sooner there would have been a 
better prospect of it being successful and further that the treatment for his cancer had been 
ef f ective. On the balance of probabilities therefore it is likely that Mr Reynolds would not have 
died on the 15th of May 2021 if the result of his scan had been acted upon when reported by the 
radiologist on the 6th of May.” 

The Cause of  Death being recorded as 1(a) Pneumonia and Pulmonary Emboli due to Deep 
Vein Thrombosis 2.Emphysema of the Lung and Carcinoma of the Oesophagus (Treated) 

4 

CIRCUMSTANCES OF THE DEATH 

The circumstances of the death are as detailed in the narrative conclusion referred to above 

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

 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.  Although it was identified quickly that existing working practices (whereby an irregular 

scan report had been placed on the desk of a clinician by a secretary and due to the 
absence of the clinician this report had not been seen and acted upon in a timely 
manner,) the health board did not fully implement a new Standard Operating Procedure, 
which was introduced to address this issue, until December 2021, seven months after 
the death of Mr Reynolds.  

2.  Furthermore an acknowledgement of the existence of the new SOP by Oncology and 

Haematology Secretaries was not completed until the 22nd of  February 2022. 

3.  Finally at the time of the inquest, eleven days prior to the anniversary of Mr Reynolds’ 
death the health board had not completed an audit process to ensure that the changes 
which had been introduced were being complied with and were therefore effective. 
I am concerned that the length of time which it takes to implement changes and to 
ensure that new saf e working practices are introduced and adopted by staff, result s in 
the health board allowing known risks to patients to continue and therefore presents a 
risk to life. 

4. 

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 
1st of  July 2022 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 6th May  2022 

Signature 
Senior Coroner for North Wales (East and Central) 

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

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 Betsi Cadwaladr University Health Board (PDF)
Bloc 5, Llys Carlton, Parc Busnes Llanelwy, 
Llanelwy, LL17 0JG 

---------------------------------- 

Block 5, Carlton Court, St Asaph Business 
Park, St Asaph, LL17 0JG 

Ein cyf / Our ref: JW/MJ/DL/3127 

Eich cyf / Your ref:    
:   
Gofynnwch am / Ask for:    

E-bost / Email:  
Dyddiad / Date: 1st July 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 
Trevor Reynolds  

I write in response to the Regulation 28 Report to Prevent of Future Deaths dated 06 May 
2022,  issued  by  yourself  to  Betsi  Cadwaladr  University  Health  Board,  following  the 
inquest touching the death of Trevor Reynolds.  

I would like to begin by offering my deepest condolences to the family and friends of Mr 
Reynolds, and I apologise for the concerns identified at the inquest that have given rise 
to your notice.  

Firstly, I would like to address the concerns regarding the length of time taken to make 
changes and how we ensure new working practices are adopted by staff.  

Within the Cancer Division, all clinicians and secretaries in oncology and haematology 
have been made aware of the Standard Operating Procedure (SOP) for the Escalation 
of Urgent Radiology Results Containing Unexpected Findings. The SOP has been added 
to the Induction Checklist for all new starters who commence within the Cancer Division 
and it has been added as a regular agenda item on all secretarial meetings. The learning 
from this matter has been shared with other health board services. 

The  Cancer  Division  have  completed  two  audits  of  compliance  with  the  SOP  (27  May 
2022 and 21 June 2022) since the notice was issued. The first audit did identify areas of 
non-compliance with the SOP, however following further training and reinforcement, the 
second audit shows the change in procedure has become embedded as normal working 
practice and there is evidence within the medical notes that action has been taken in all 
cases. Ongoing monthly audits of the process will be completed and the findings will be 
reported  formally  to  the  Cancer  Services  Governance  Meeting.  The  SOP  has  been 
updated following the results of the audits so far and will be regularly reviewed along with 
future audit findings. 

Ysbyty Gwynedd, Penrhosgarnedd 
Bangor, Gwynedd LL57 2PW 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In respect of diagnostic results and follow up, I am aware this is an issue that you have 
raised previously, and despite the introduction of written procedures, this does remain a 
concern. We accept that a resilient solution is needed. 

Last year, the Health Board established a Results Management Project with the aim of 
eliminating  printed  or  hard  copy  results  and  integrating  reporting  to  our  digital  clinical 
system  known  as  the  Welsh  Clinical  Portal.  This  work  has  been  developed  in 
collaboration with Digital Health and Care Wales, the national NHS Wales organisation 
who manage many of our digital clinical systems. I am pleased to advise this development 
work has  been  completed  and  the new  electronic functionality  has  been  tested  and  is 
ready for roll-out. 

Following your notice, our senior medical and quality teams have discussed rapid rollout 
of this electronic solution. Our intention is to implement this new digital solution over the 
summer with our respiratory speciality as an early adopter service, with the learning from 
that implementation informing full roll-out across the health board by the end of the year. 
A formal evaluation covering the implementation will then take place in January/February 
2023.  

We have reviewed the case of Mr Reynolds in detail following the inquest and note that 
the investigation report was completed within the required time and the action plan stated 
reasonable deadlines; however, these deadlines where not achieved and as you have 
identified the delivery of actions was unacceptably delayed.  

To  improve  internal  oversight,  our  bi-monthly  Patient  Safety  Report  (from  June  2022 
onwards) will provide a breakdown of all overdue actions by division and service. This 
report is presented to our Executive-led quality  group and ultimately our Board quality 
committee.  This  will  ensure  the  visibility  of  action  delivery  performance  and  enable 
divisions to be held to account for their performance through these governance forums 
and through their Accountability Review Meetings. 

Additionally,  we  will  shortly  be  undertaking  an  organisational  change  process  for  our 
quality function and this will provide greater clarity and expectation for quality staff based 
locally  within  divisions.  They  will  operate  in  a  business  partner  model,  providing  local 
support  at  directorate  and  divisional  level  with  a  key  part  of  their  role  supporting, 
challenging and reporting on action delivery. We are currently finalising the proposal for 
this function with a view to the changes taking place over the coming months. A workshop 
for staff has been arranged for 14 July 2022. This work links to our wider organisational 
development  strategy  called  Stronger  Together,  which  is  also  implementing  a  new 
operating  structure  for  divisions  and  new  leadership  roles  with  clearly  defined 
responsibilities (this includes delivery of improvement work). This new divisional model 
is planned for implementation during late summer 2022. I have provided broad delivery 
dates - the exact dates for this work will be finalised shortly following conclusion of certain 
workforce change processes.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Additionally, we are currently in the process of reviewing our approach to clinical audit. 
We will closer align our audit programme with the risks that we have identified through 
issues  such  as  serious  incident  reporting  and  inquest  matters. We  have  also  recently 
procured a new electronic audit system and we are in the process of rolling this out. This 
system will improve the digital completion of audits and the reporting of assurances.   

Taken together, the improved clarity of new leadership roles, improved local support for 
quality,  improved  visibility  of  performance  reporting,  and  a  strengthened  approach  to 
clinical audit, will allow us to strengthen the timely delivery of actions and the visibility of 
performance across the organisation.  

I hope my letter offers you assurance that we have worked to address the concerns you 
identified.  

One again, please may I offer my condolences to the loved ones of Mr Reynolds. 

Should  you  require  any  further  information  or  evidence  of  the  actions  outlined  above 
please contact either myself or Matthew Joyes, Associate Director of Quality.   

Yours sincerely 

Prif Weithredwr/Chief Executive

Related reports

Other reports by John Gittins

See all →

More reports categorised “Hospital Death (Clinical Procedures and medical management) related deaths”

See all →

Track Hospital Death (Clinical Procedures and medical management) related deaths

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.