Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0298, written 17 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 17 Aug 2023 |
|---|---|
| Reference | 2023-0298 |
| Deceased | Malcolm Unwin |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| 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.
John Gittins Senior Coroner for North Wales (East and Central) 1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Betsi Cadwaladr University Health Board (BCUHB), CORONER I am John Gittins, Senior Coroner for North Wales (East and Central) 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 the 23rd of January 2023 an investigation was commenced into the death of Malcolm Ralph Unwin (DOB 15/03/43) who died at Wrexham Maelor Hospital on the 6th of January 2023. The conclusion of the inquest on the 16th of August 2023 was that the death was due to an accident. CIRCUMSTANCES OF THE DEATH On the 30th of December 2022 the deceased had unwitnessed fall from bed whilst a patient at the hospital resulting in injuries. The cause of death being 1(a) Head Injury with skull fracture and diffuse axonal injury (b) Mechanical Fall (c) Frailty associated with bladder cancer and prostate cancer. 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 was no evidence that the deceased had been assessed for bed rails, whilst in hospital although it is probable that they were in due at the time of his fall. Evidence was given that the bed rail assessment is not currently a part of the Welsh Nursing Care Record which staff access via iPad. In the absence of this being a part of the WNCR I am concerned that this assessment may be missed, and that future death may occur as a result. 6 ACTION SHOULD BE TAKEN Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN 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 12th October 2023. I, John Gittins, the Coroner, may extend the period. I would be prepared to accept a joint response from all organisations. 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 17th August 2023 Signature Senior Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
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 Dyddiad / Date: 10 October 2023 John Gittins HM 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 Malcolm Ralph Unwin I write in response to the Regulation 28 Report to Prevent Future Deaths dated 17 August 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching upon the death of Mr Malcolm Unwin. I would like to begin by offering my deepest condolences to the family and friends of Mr Unwin for their loss. In the Notice, you highlighted your concerns that the bed rail assessment is not part of the new national Welsh Nursing Care Record (WNCR) system and as such completion of this form may be missed. In response to the Notice, I requested our senior nursing leads to carefully consider your concerns and provide details of the plans to make our services as safe as possible, taking into account the learning from the inquest. As you know, the WNCR was created by Digital Health and Care Wales working with nurses and other colleagues across NHS Wales to create a digital system with standardised nursing documentation. The WNCR has been rolled out across all inpatient services in the Health Board, except one community hospital in our west area which will soon be finalised. Additionally, in June of this year we successfully migrated to a single instance of the system across all services in North Wales. As part of the move to WNCR, national nursing standards were necessary to address the document duplication and inconsistencies in nursing records across Wales. Key to the development of these standards was organisational and multidisciplinary collaboration across NHS Wales. 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 All standards were supported by a governance assurance process, which incorporated end to end nursing governance that included specialist nurses and current best practice evidence recommendations from multidisciplinary specialist groups. As you identified, the bed rails assessment has not yet been through the nursing standardisation and governance process meaning there is not yet a single version to be incorporated into this national system. Following your Notice, we raised this issue nationally in order to expedite this process. The issue was discussed at the National Deputy Directors of Nursing Meeting on 07 September 2023, and in response Cwm Taf Morgannwg University Health Board has taken the lead in establishing a national working group to create a standardised bed rails assessment tool across Wales, and to propose this single version for inclusion in the WNCR. As this is national, collaborative work involving all Health Boards and Trusts in NHS Wales then I cannot advise a specific completion date. However I can confirm that this will remain open on our action tracker and should the matter be delayed, it will be escalated for executive director intervention. We have also added this issue to our risk register until the transition to the WNCR is complete. This risk will be owned by our patient safety team and senior nursing team which will ensure the issue, and the risk to patient safety, remains visible until the national work is complete. In the interim period, I can confirm we have written to all ward managers, matrons and heads of nursing reminding them of the process for paper based assessment forms. We have provided information which can be used on ward safety briefs with staff and which can also be visibly placed in wards to remind staff. We are also in the process of finalising our updated Bed Rails Procedure which will be live within the next few weeks. Finally, I would also advise that the Welsh Government (WG) and the Medicines and Healthcare products Regulatory Agency (MHRA) issued a National Patient Safety Alert on 30 August 2023 which includes safety considerations around bed rails. We are currently working through the actions required to comply with this alert and developing our response, which requires actions to be completed by 01 March 2024. I hope this letter sets out for you the actions we have taken to ensure the concerns you raised are being addressed. We would be happy to meet with you further and discuss our plans in more detail, or provide further information and assurance should that be helpful. Once again, I offer my deepest condolences to the family and friends of Mr Unwin for their loss. Yours sincerely Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro Executive Medical Director / Acting Deputy Chief Executive cc , Deputy Director of Quality
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