Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0236, written 10 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Jul 2023 |
|---|---|
| Reference | 2023-0236 |
| Deceased | Mary Jones |
| Coroner | Kate Robertson |
| Coroner area | North West Wales |
| Category | Wales prevention of future deaths reports (2019 onwards) · Emergency services related deaths (2019 onwards) |
| 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 Robertson Senior Coroner for North West Wales REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Betsi Cadwaladr University Health Board (BCUHB), Welsh Ambulance Service Trust (WAST), North Wales Local Authorities 1 CORONER I am Kate Robertson, 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 19 January 2023 an investigation was commenced into the death of Mary Elizabeth Jones (DOB 30/12/36) who died on 14 January 2023. The investigation concluded at the end of the inquest on 7 July 2023. The conclusion of the inquest was that Mary Elizabeth Jones had died from natural causes contributed to by a fall. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows :- On Sunday 4th December 2022 at around 10am Mary Elizabeth Jones had an unwitnessed fall at home. An ambulance was called which arrived 26 hours and 23 minutes later. She was taken to Ysbyty Gwynedd. She remained on the back of the ambulance due to Emergency Department pressures for a further 8 hours and 23 minutes. She was assessed by a doctor on the back of the ambulance at around 8pm on 5th December. CT scan of her pelvis identified an undisplaced fracture. She deteriorated on 17 December 2022 with low blood pressure and abdominal tenderness and a new oxygen requirements and was receiving antibiotics for a suspected urinary tract infection. By early January 2023 a further deterioration was noted – she was drowsy and eating less and her blood tests showed a drop in haemaglobin. She had a blood and iron tranfusion. An abdominal bleed was diganosed on 6th Janaury and she had a poor prognosis. Palliative care was commenced and she sadly passed away on 14 January 2023 certified at 18:00 hours at Ysbyty Gwynedd. Coroner's Office, Shirehall Street, Caernarfon 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 – This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales. Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones. I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. 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 4 September 2023. I, Kate Robertson, the Coroner, may extend the period. I am willing to accept a joint response from all to whom this Report is made. 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 Coroner's Office, Shirehall Street, Caernarfon 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 of this Report to Eluned Morgan, Health Minister, for her information. 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 10 July 2023 Signature Kate Robertson HM Senior Coroner for North West Wales Coroner's Office, Shirehall Street, Caernarfon
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.
Swyddfa'r Prif Weithredwr a’r Cadeirydd Chair and Chief Executive’s Office 2 November 2023 PRIVATE & CONFIDENTIAL Ms Kate Robertson H.M. Senior Coroner for North West Wales Dear Ms Robertson Re: Mrs Mary Elizabeth Jones I write in response to the Prevent of Future Deaths Report issued to this Trust on the 10 July 2023, following the inquest. Firstly I would like to apologise for the delay in responding to you in relation to this matter. Also, can I please pass on apologies from , Assistant Director of Quality and Nursing Directorate. The matters of concern that you have asked the Trust to consider are:- This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales. Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones. 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 I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. At this time and in specific response to this Prevention of Future Deaths Report, the Trust does not propose to take any further action or new actions in relation to this matter. The Trust is taking all possible steps within its control to ensure availability of resources to respond to Red and Amber calls. The Trust also seeks to secure full support from Welsh Government, the wider NHS and local Government to ensure appropriate clinical risk management across the urgent and emergency care pathways to release resources with the Trust. The Trust has previously shared with you that it is represented on the North Wales Regional Partnership Board, which brings together a range of statutory and non-statutory partners, including Local Authority representation at both officer and member level, focused on improving collaborative services provided to the people of North Wales, including older people. The Trust has evidenced this work through the comprehensive details of all the actions that we have taken to date, and I have also shared with you the measures that are currently in place, such as the Clinical Safety Plan and the Regional Escalation Action Plan. I have not attached copies of these Plans again, as I have previously supplied them. I have shared with you copies of the Real-time Mitigation Report and the Reducing Patient Harm Action Plan, both of which were presented to the Public Trust Board on the 27 July 2023. This Report is regularly presented to, and reviewed by, the Trust Board and I hope this offers you assurance that this matter continues to remain a significant risk and a matter of attention to the full Trust Board. While the Trust fully supports the need to issue a Report under Paragraph 7, Schedule 5, of the Coroners & Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, we do not believe that we are the authority with the “power to take such actions”. Therefore, I respectfully request your consideration as to any further actions you feel the Trust could take, over and above those we have already shared with you. Equally, I would genuinely welcome any suggestions you may have regarding actions we might take or seek to take with our partners. To reaffirm my earlier comment, we believe we have robust plans in place which are regularly critiqued and monitored throughout the organisation. The issues arising are presented to our full Trust Board and we liaise directly with the Health Boards and wider health and social care partners across Wales in order to secure their support to ensure that we respond to Red and Amber calls in a timely way. While writing I would again like to offer my sincere condolences to Mrs Jones’s family on their sad loss. I would like to extend the offer to meet with you and leaders of other key organisations to discuss our response in more detail, and to provide you with any further assurances you may require regarding our commitment to continued improvement to support the prevention of harm and future deaths. Yours sincerely Chief Executive 2
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