Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0333, written 24 Oct 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Oct 2022 |
|---|---|
| Reference | 2022-0333 |
| Deceased | Glendys Roberts |
| Coroner | Kate Sutherland |
| Coroner area | North West Wales |
| Category | Emergency services related deaths (2019 onwards) · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Welsh Ambulance Service Trust Betsi Cadwaladr University Local Health Board 1 CORONER I am Kate Sutherland, Acting Senior Coroner for North West Wales 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 26 August 2021, an investigation was commenced into the death of Glenys Roberts. The investigation concluded at the end of an Article 2 compliant Inquest on 18 October 2022. A narrative conclusion was given:- At around 5pm on 23 August 2021 Glenys Roberts was found by a passer-by on the floor by her front door. Glenys Roberts was complaining of pain and loss of sensation in her legs. She was conveyed to Ysbyty Gwynedd and arrived at 19.46. Assessment in the Emergency Department of Ysbyty Gwynedd led to a diagnosis of saddle embolus of the aortic bifurcation. With vascular across the Health Board centralized at Ysbyty Glan Clwyd, some 30 miles away, the Consultant at Ysbyty Gwynedd discussed Glenys Robert’s case with the vascular consultant on call based at Ysbyty Glan Clwyd at 21.19 hours who advised 5000 unit bolus dose of intravenous heparin and CT angiogram ad emergency ambulance transfer to Ysbyty Glan Clwyd. The CT angiogram revealed a complete occlusion of the distal aorta. Arrangements were made for Glenys Roberts to be admitted directly onto a ward at Ysbyty Glan Clwyd rather than being admitted via the Emergency Department to prevent delays whilst being admitted. There was, however, a failure to convey Glenys Roberts by ambulance from Ysbyty Gwynedd to Ysbyty Glan Clwyd in a timely manner or at all for vascular surgery. Glenys Roberts continued to deteriorate and became too frail to be conveyed to Ysbyty Glan Clwyd when an ambulance became available to 05:15. Glenys Roberts was certified deceased in Ysbyty Gwynedd at 07.39 on 24 August 2021. There was a missed opportunity for Glenys Roberts to undergo vascular surgery by not being conveyed to Ysbyty Glan Clwyd thereby failing to optimize an opportunity for life saving surgery but it cannot be said that this would have altered the outcome for her. 4 CIRCUMSTANCES OF THE DEATH These were recorded as :- See narrative conclusion for findings 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. – There were no available ambulance resources to convey Glenys Roberts from Ysbyty Gwynedd to Ysbyty Glan Clwyd. The reason for this being multifactorial but particularly due to fit patients remaining in hospital due to no community care available to them, thereby remaining in hospital and limiting patient beds. Whilst action is being taken by WAST and BCUHB the following concerns remain:- 1. Review of and action relating to intra hospital transfers has been too slow 2. Review of the current vascular pathway to ensure vascular emergency transfers have direct admission into hospital is still not fully operational and has been too slow 3. Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisations 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 12 December 2022 Only, 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 also sent a copy of my report to Glenys Roberts’ family and , Minister for Health and Social Services 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 24 October 2022 SIGNED: Kate Sutherland, Acting Senior Coroner for North West Wales 2
2 responses 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 BusnesLlanelwy, Llanelwy, LL17 0JG ---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG Kate Sutherland Acting Senior Coroner for North West Wales HM Coroner’s Office Shirehall Street Caernarfon Gwynedd LL55 1SH Dyddiad / Date: 12 December 2022 Dear Ms Sutherland, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Glenys Roberts I write in response to the Regulation 28 Report to Prevent Future Deaths dated 24 October 2022, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Glenys Roberts. I note that the Welsh Ambulance Service Trust, as joint parities to the Notice, will also respond to you. I would like to begin by offering my deepest condolences to the family and friends of Mrs Roberts. In the Notice, you highlighted concerns regarding the progress of improvements following Mrs Roberts’ death. I would like to address the concerns you raised below: Review of and action relating to intra hospital transfers has been too slow The review and actions for the intra hospital process is ongoing, with support from the National Collaborative Commissioning Unit (NCCU), to assist the review in line with similar national work that has commenced. The actions from the review of the intra hospital transfer process has resulted in significant work to model the service demand and draft an options appraisal for future development, to support additional resources required. As detailed below, we have made changes to the vascular pathway and implemented a change in protocol that in the event a paramedic crew is not able to transfer the patient between hospital sites in a timely manner, then the the Ambulance Critical Care Team (ACCT) will transfer the patient. Review of the current vascular pathway to ensure vascular emergency transfers have direct admission into hospital is still not operational and has been too slow Prior to the Inquest, the Health Board had recognised these delays in time critical pathways and work had commenced on mapping out the current Emergency Ischaemic Limb Pathway across all three hospitals in North Wales. This was a multi-disciplinary approach including Emergency Departments (EDs), diagnostic services, pharmacy 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.bipbc.gig.cymru / Web: www.bcuhb.nhs.wales teams, operational teams, vascular teams and the Welsh Ambulance Service Trust (WAST). Work has progressed steadily with regular transformational sessions across all three sites led by the vascular network team. To date the following actions have taken place: Process mapping of the patient journey from point of referral to WAST and mode of arrival in to the ED; identifying the bottlenecks and delays in the patient journey and taking steps to reduce the delay. A change in protocol that in the event a paramedic crew is not able to transfer the patient between hospital sites in a timely manner the Ambulance Critical Care Team will transfer the patient. In order to avoid the need for a paramedic crew to transfer the patient between hospitals, a change in clinical protocol from an Intravenous Anticoagulant Infusion to a bolus dose has been agreed. This means that a non-paramedic crew, which are more readily available, can convey the patient. Vascular surgeons and the emergency department clinicians have agreed to support the implementation of the South East Wales WAST Bypass Pathway. WAST crews will contact the Vascular Consultant having confirmed an emergency ischaemic limb and if the patient is stable they will be accepted and go straight to the vascular ward, by-passing ED. This is commencing from 01 December 2022 and will be monitored fortnightly through regular meetings with all key stakeholders to address issues or concerns which arise. This will continue until all parties are confident that the new pathway is fully embedded. I have enclosed a copy of the Clinical Notice and Vascular Emergency Bypass Pathway confirming these changes. Development of a pan Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow An integrated commissioning action plan (ICAP) has been completed following on from the Health Minister’s Summit on Monday 28 November 2022, to support the rapid improvement in performance as part of the national six goals programme for urgent and emergency care. The Health Board and WAST have a fortnightly review meetings with the NHS Wales Delivery Unit on ambulance performance in line with the initial zero tolerance of delays greater than 2 hours, with a national plan being developed to have a zero tolerance on 1 hour delays during 2023-2024. The local Ysbyty Gwynedd handover plan has been shared across sites within the Health Board for local adoption, along with ED full protocols and hospital full protocols. These are aligned with the national Operational Pressures Escalation Levels (OPEL) with clear triggers to support de-escalation and reducing delays. I have enclosed a copy of the integrated commissioning action plan. We would be keen to present to you the work being done across North Wales on urgent and emergency care, aligned to the Welsh Government national programme. I hope my letter offers you assurance that we have worked to address the concerns you identified. Significant change to clinical protocols have been made across North Wales involving multiple specialisms and organisations, and we have sought to implement these in a safe and effective way. One again, please may I offer my condolences to the loved ones of Mrs Roberts. Should you require any further information or evidence of the actions outlined above please contact us. Yours sincerely Prif Weithredwr Dros Dro Interim Chief Executive CC. Executive Medical Director Matthew Joyes, Associate Director of Quality Enc. Clinical notice Vascular Emergency Bypass Pathway Integrated Commissioning Action Plan
Swyddfa'r Prif Weithredwr a’r Cadeirydd Chair and Chief Executive’s Office 12 December 2022 PRIVATE & CONFIDENTIAL Ms Kate Sutherland Acting Senior Coroner for North West Wales Dear Ms Sutherland Re: Glenys Roberts I write in response to the Prevention of Future Deaths Report issued to this Trust on 24 October 2022, following the inquest in relation to Glenys Roberts. You have asked the Trust to consider 3 specific areas: 1. Review of and action relating to intra hospital transfers has been too slow. The Trust has engaged with Betsi Cadwaladr University (BCU) Health Board and the National Collaborative Commissioning Unit (NCCU), meeting on a fortnightly basis, to work through an action plan that will support the improvement in availability of resources to undertake transfers. A key issue is the ongoing lack of ambulance availability due to our resources being delayed at hospitals. Therefore, the Trust has offered to develop a longer-term solution for intra hospital transfers which could employ dedicated resources to move patients in a timely manner. As the Trust is a commissioned organisation there is high reliance on BCU Health Board and NCCU commissioning additional services. We have evidence of successful deployment elsewhere in Wales, namely in the Aneurin Bevan University Health Board, where the health board commissioned dedicated services. Mae’r Ymddiriedolaeth yn croesawu gohebiaeth yn y Gymraeg neu’r Saesneg, ac na fydd gohebu yn Gymraeg yn arwain at oedi The Trust welcomes correspondence in Welsh or English, and that corresponding in Welsh will not lead to a delay www.ambulance.nhs.wales Anfonwch unrhyw ohebiaeth i'r cyfeiriad canlynol:- Please forward any correspondence to the following address:- Beacon House William Brown Close Llantarnam Cwmbran NP44 3AB Ffôn/Tel 01633 626262 In order to develop a proposal the Trust and BCU Health Board need to validate data to determine the demand for such a service within prudent healthcare principles. However, given that patient safety and the prevention of future deaths is the overarching consideration, BCU Health Board has been discussing a solution that can be put in place quickly using the All Wales Critical Care Transfer Service (ACCTS), by way of an expansion to their current service model. The Trust will then continue to work with BCU Health Board, ACCTS and NCCU to develop and commission a longer term model and aim to present this in Quarter 4 of this financial year. 2. Review of the current vascular pathway to ensure vascular emergency transfers have direct admission into hospital is still not fully operational and has been too slow The Trust has developed a bypass protocol for patients presenting with the need for vascular services following a change to Joint Royal Colleges Ambulance Liaison Committee guidelines. This includes a range of conditions including abdominal aortic aneurysms (AAA) and ischemic limb, and has been implemented in the South East Wales Vascular network. BCU Health Board Vascular Network has accepted part of this pathway, the immediate bypass for ischemic limb to Ysbyty Glan Clwyd, but not for AAA. The Trust is currently finalising the pathway with BCU Health Board for implementation. A draft document has been shared with BCU Health Board on 22 November 2022 to provide some BCU Health Board specific demographic and service delivery information, along with terminology although this can be considered non-essential with regard to implementation of the pathway and will not delay the release of this document to staff. The Trust is still waiting for a direct dial contact number that can be added to Consultant Connect and a destination for crews when patients have been accepted through this pathway. Once we have the information from the Health Board the information can be released for immediate use. 3. Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow The Handover Improvement Plan has been put in place between the Trust, BCU Health Board and NCCU, along with fortnightly meetings chaired by NCCU. Going forward these meetings will be the host for integrated commissioning action plans, part of the refreshed Emergency Medical Services Commissioning Framework approved by Emergency Ambulance Services Committee. These plans will incorporate transformative actions that can be put in place to improve system flow, avoid conveyance and support timely discharge and transfer of patients, aligning to the Welsh Government Six Goals for Urgent and Emergency Care programme. These meetings are due to commence in December 2022. The Trust is also working with BCU Health Board outside of the intra hospitals transfer group on the availability of non- conveyance pathways to support the work to improve system flow. The Trust has previously provided evidence to Coroners in North Wales regarding the actions that have been taken in order to reduce the lost hours and improve our response times to patients waiting in the community. I have attached the most up to date action plan (Reducing Patient Harm Action Plan). This plan has been tabled in the organisation’s Trust Board meetings since July 2022. 2 I attach for your reference a plan that lists the actions the Trust is proposing to consider in order to address the issues highlighted within your Regulation 28 report. Any changes made will be included within the Trust’s Standard Operating Procedures (Clinical Contact Centre and Clinical Support Desk). This is in addition to the action plans that formed part of the BCU Health Board investigation which they lead on. Whilst I was pleased to hear that staff from this Trust and the BCU Health Board were able to provide you with details of ongoing joint work in relation to the issues that you have raised in this report, I feel it is incumbent on me to stress that unless there is a significant reduction in the number of ambulance hours lost due to delays at hospital, the Health Board will need to determine if they commission transfer services from the Trust. I have previously shared with you, in my response relating to the Prevention of Future Deaths report in respect of Mr Raymond Gillespie, the actions that the Trust has taken in an attempt to minimize the impact of ambulances being delayed at hospital, when handing over the care of patients. Whilst writing I would like to extend my sincere condolences to Mrs Roberts family on their sad loss. I would also like to extend the offer to meet with you to discuss our response in more detail and to provide you with any further assurances you may require regarding our commitment to continual improvement to support the prevention of future deaths. Yours sincerely Chief Executive 3
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