Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0205, written 21 Apr 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Apr 2023 |
|---|---|
| Reference | 2023-0205 |
| Deceased | Maria Shafighian |
| Coroner | Caroline Saunders |
| Coroner area | Gwent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013 REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 1 2 3 THIS REPORT IS BEING SENT TO: The Chief Executive of Aneurin Bevan University Health Board. CORONER I am Caroline Saunders, Senior Coroner for the Area of Gwent 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 INVESTIGATION AND INQUEST On 10/12/2020 an investigation was opened into the death of Maria Christine Shafighian The investigation concluded at the end of the inquest on: 6/4/2023 The conclusion of the inquest was recorded as: Death from Natural Causes The medical cause of death was: 1a. Metastatic oesophageal cancer. 4 CIRCUMSTANCES OF THE DEATH Maria Shafighian was a 59-year-old woman who was referred to the ENT department at Aneurin Bevan University Health Board by her GP on 27/1/2020 with symptoms of persistent hoarseness. Ms Shafighian was assessed by a specialist ENT trainee on 3/2/2020 who ordered a CT scan, which found no evidence of laryngeal cancer. Maria was diagnosed with vocal cord palsy and referred to the Speech and Language Therapists (SALT). On 4/5/2020 the SALT team noted that Maria was suffering from dysphagia which I heard was a worrying development which may need urgent assessment. I heard that the SALT team referred Maria back to the ENT team and notified them of this development. After further assessment, Maria was diagnosed with oesophageal cancer. She was not a candidate for surgical intervention and received palliative chemotherapy and radiotherapy. Maria Shafighian died from the effects of oesophageal cancer at Ysbyty Ystrad Fawr on 24/11/2020 In the inquest I determined that there had been opportunities missed to identify and treat Maria’s tumour earlier but I could not determine on balance that this would have altered the outcome and hence the conclusion was death by natural causes. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: - During the inquest I heard that the process by which the SALT team notified the ENT department of the change in Maria’s presentation and the development of dysphagia was through an internal postal system. Following assessment by SALT on 4/5/2020, a letter was written to the ENT team which was printed and left in a pigeon hole. No evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team and there was no process for ensuring that the post was dealt with in a timely manner. In Maria’s case there appears to have been a delay of a month between the letter being sent and being noticed by the ENT team. 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. I should be grateful if the following information be provided to me: Confirm the processes that are in place to ensure that changes in patients’ presentation are brought to the attention of the appropriate clinical teams in a timely fashion and the policies which are in place to underpin the use of alert systems and the internal postal service. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 16 June 2023. I, the Coroner, may extend this 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 necessary 8 COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) • The family of Maria Christine Shafighian 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 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 DATE 21/4/23 Signed Caroline Saunders His Majesty’s Senior Coroner for the Area of Gwent.
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.
12th June 2023
PRIVATE AND CONFIDENTIAL
Caroline Saunders
Senior Coroner (Gwent)
Dear Ms Saunders
Re: Maria Christine Shafighian
Thank you for your letter following the conclusion of the inquest into Ms
Shafighians death and the request to outline the actions taken to comply with
regulation 28 Prevention of Future Deaths.
To respond to internal processes for managing Ear,Nose,Throat(ENT) referrals
from other specialties.
The current process for internal referrals is that a referral letter may be sent
directly to the ENT department, where it will be seen and triaged by a
consultant, then forwarded to the Central Registration department, where it is
loaded onto the Clinical Workstation. These referrals are then sent
electronically to the Consultants in ENT for triage. The triage involves review
and prioritisation of the referrals as Urgent Suspected Cancer, Urgent and
Routine. Following triage, the patient’s details are updated on Clinical
Workstation. Patients are then placed on the waiting list, and an
acknowledgement letter is sent to the patient.
For patients listed as an Urgent Suspected Cancer (USC) there is a tracking
system that monitors them through the patient pathway until completion or
commencement of treatment.
In the case of Ms Shafighian, the patient was seen and assessed in ENT and
was then discharged from ENT to the Speech and Language therapy (SALT)
service. During a video consultation, the SALT therapist noted that Ms
Shafighian was struggling to swallow, so a referral was sent to ENT for an
urgent opinion.
Pencadlys
Ysbyty Sant Cadog
Ffordd Y Lodj
Caerllion
Casnewydd
De Cymru NP18 3XQ
Ffôn: 01633 436700
Headquarters
St Cadoc’s Hospital
Lodge Road
Caerleon
Newport
South Wales NP18 3XQ
Tel No: 01633 436700
Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan
Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board
This referral letter typed by SALT is uploaded onto the MedSecs system, and
the GP is sent a copy. The letter was then printed and sent to the ENT
department manually (as outlined in the report). This referral letter would then
be seen by one of the ENT Consultants, triaged and then sent to Central
Registration for them to upload onto the Clinical Workstation system. At this
point, an acknowledgement would be sent to the patient informing them of this
waiting list entry.
In order to improve the system, speed up the process, and provide a more
robust audit trail of referral demands, it has been discussed and agreed that
internal referrals to the ENT department need to be sent straight to the Central
Registration department for them to take action and upload the information
on the referral, and send this electronically to the ENT consultants for triage.
This would mirror the GP process.
In addition,
Head and Neck MDTs and supporting services that for any urgent clinical
developments requiring an ENT opinion, these should also be e-mailed.
Head and Neck Cancer Lead, has communicated to the
The Directorate is also in the process of developing a generic internal electronic
referral form that would need to be completed for any patients needing ENT
input or an opinion. This would remove the need for paper letters or referrals
to be sent, speed up the process, and provide an audit trail of receipt and
action on the system.
The provision of an internal e-referral process will speed up the process,
reduce the risk of referrals being delayed or lost in the system, and provide an
audit.
I hope this response outlines the current process and actions that the Health
Board has taken and is in the process of taking. If you have any further
questions, please contact
Neck Services on
who would be happy to discuss this with you.
Directorate Manager Head and
Yours sincerely
Prif Weithredwr/Chief Executive
2
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