Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0185, written 8 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Jun 2023 |
|---|---|
| Reference | 2023-0185 |
| Deceased | Eifion Huws |
| Coroner | Kate Sutherland |
| Coroner area | North West Wales |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Kate Sutherland
HM Senior Coroner for North West Wales
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Betsi Cadwaladr University Local Health Board
1
CORONER
I am Kate Sutherland, HM 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 21 June 2022 an investigation was commenced into the death of Eifion Wyn Huws
(DOB 25/4/59) who died on 10 June 2022. The investigation concluded at the end of
the inquest on 7 June 2023. The conclusion of the inquest was suicide.
4
CIRCUMSTANCES OF THE DEATH
The circumstances of the death are as follows :
Eifion Wyn Huws was aged 63 at the time of his death on 10 June 2022. He had a past medical
history of non-Hodgkin’s lymphoma having had the diagnosis on 12 January 2022 and poorer
mental health as a result. Other than the lymphoma he had no other significant past medical
history. The anticipation of awaiting scans and treatment impacted severely upon his mental
health but he had significant family support. Eifion was regularly reviewed by a GP and
medicated accordingly. He had previous attempts at self-harm by way of medication overdose
or self-inflicted injury. He had been under the care of the Community Mental Health Team
including Home Treatment Team and primary care since early 2022 up to his death. His acts of
self-harm were impulsive but serious. On 10 June 2022 Eifion had left his home address to
attend his daughter’s home across the road to let the cat out. There was a concern for Eifion
when he did not reply to a text message from his wife around 15 mins later who then attended
at their daughter’s home and on opening the front door found Eifion suspended by a ligature
. Eifion was confirmed as having passed away at the
property on 10 June 2022 at 10.37 by an attending paramedic.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
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. a. During the Inquest evidence was heard that Eifion’s GP had made a ‘very
urgent’ referral to the Single Point of Access and Allocation (SPOAA) on 13 May
2022 indicating that on the background of attempts at ending his life, he was
extremely concerned that Eifion was experiencing deterioration in his mental
state. This document was contained within the hard copy set of notes held by
the Psychiatric Liaison Team. When Eifion attended at the Emergency
Department the following day, on 14 May 2022, the Emergency department
staff were not aware of this ‘very urgent’ referral as they only had access to the
electronic notes and not the hard copy notes. Had they been aware it is likely to
have further informed their decision making. It is concerning that the process of
ensuring electronic notes to allow for fully informed decisions around treatment
and care based on all available records, is not available to staff. It was not clear
at Inquest whether the transition from paper-based notes to electronic notes
was a Health Board initiative or a nationally followed initiative. Either way, any
delay in ensuring all notes are available electronically is potentially harmful to
patients.
b. During the evidence it was accepted that ‘a’ above was not a consideration
for improvement as part of the Health Board’s investigation and so was not an
action within the Action Plan upon which it could make improvements or plan
to make improvements. It is surprising that the Health Board did not consider
this as an issue which required further consideration and improvements in its
learning and improvement.
2. An investigation was commenced by the Health Board into Eifion’s death which
appears to have been concluded in July 2022 but did not appear to be finalised
and ready for sharing / disseminating until March 2023. I have previously issued
Prevention of Future Death Reports to the Health Board pertaining to the lack of
timeliness of their investigations, specifically in relation to investigations from
deaths in 2020 and 2021. Whilst I have previously been advised of
improvements into investigation processes in respect of more recent deaths the
issue of timeliness remains. Eifion died in 2022 and yet the time it took for the
investigation to be completed and shared, with actions undertaken has been
too long. I am concerned that deaths will occur when the actions arising are not
acted upon in a timely manner.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
|
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 3 August 2023. I, Kate Sutherland, 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 have also sent a copy to Eluned Morgan, Heath Minister.
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 8 June 2023
Signature
HM Senior Coroner North West Wales
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
Tel 01824 708047 |
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 BusnesLlanelwy, Llanelwy, LL17 0JG ---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG Kate Robertson Senior Coroner for North West Wales HM Coroner’s Office Shirehall Street Caernarfon Gwynedd LL55 1SH Dyddiad / Date: 31 July 2023 Dear Ms Robertson, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Eifion Wyn Huws I write in response to the Regulation 28 Report to Prevent Future Deaths dated 08 June 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Mr Eifion Wyn Huws. I would like to begin by offering my deepest condolences to the family and friends of Mr Huws for their loss. In the Notice, you raised a number of concerns. In response to the inquest and the Notice, I requested our Mental Health and Learning Disability Division (MHLD) to carefully consider your concerns and provide details of their plans to make our services as safe as possible. The findings of those considerations and our actions are detailed below. The Welsh Government have advocated the use of an information technology (IT) system that links health and social care through the use of an integrated care platform. The Welsh Community Care Information System (WCCIS) will enable a single integrated health and social care record. This system will help social services (adults & children) and a range of community health services (including mental health, therapies and community nursing) to ensure that care and support for individuals, families and communities are more effectively planned, co-ordinated and delivered. It will support information sharing requirements, case management and workflow for health and social care organisations across Wales. It will show where a patient is within their treatment journey and alert health professionals to key data, which will support the delivery of effective treatment. WCCIS will interface with a range of other appropriate systems across local authorities and NHS organisations wherever a patient is treated, in their own home, in the community or in a hospital. Our MHLD Division engagement in the WCCIS Project is ongoing, however its implementation has faced national delays. The Health Board WCCIS Project Team engaged with MHLD services to review system functionality and identified that further 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 national development work was required to meet our requirements. This work has been ongoing in parallel and conjunction with all Health Boards in Wales. The Health Board’s implementation of WCCIS is monitored organisationally through the WCCIS Project Board. With regard to the investigation report and action plan into the care and treatment delivered to Mr Huws, the benefits of an integrated IT system should have been considered with reference to the implementation of WCCIS within the action plan and this has been discussed with the investigating officer. I would like to sincerely apologise for the delays in the completion and timeliness of the investigation report and the implementation of the subsequent action plan. I have acknowledged before, in a previous letter to you, the unacceptable impact on patients, families and the coronial process from delays in investigations and actions plans and I remain firm in my commitment to improve our responsiveness. In my previous letter to you on 09 May 2023, I was able to inform you of the changes that have taken place within the Health Board; these included a review of the incident process, and the quality control process delivered by the quality governance teams. The Health Board have also implemented rapid learning panels and incident learning panels. The MHLD Division have prioritised the completion of overdue investigations and action plans and there has been a significant reduction in the number overdue. The Division continues to meet weekly to address any remaining overdue investigation reports and to ensure that actions are monitored for completion. I recognise the importance of ensuring this improvement is maintained and I am assured that we have the mechanisms in place to monitor this and to take further action as required. I hope this letter sets out for you the actions taken to ensure the concerns raised by yourself and Mr Huws’ family are being addressed. Once again, I would like to offer my deepest condolences to the family and friends of Mr Huws for their loss. Yours sincerely Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro Executive Medical Director / Acting Deputy Chief Executive cc , Executive Director of Public Health , Deputy Director of Quality
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