Prevention of Future Deaths reports · 2023

Malcolm Unwin

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 report17 Aug 2023
Reference2023-0298
DeceasedMalcolm Unwin
CoronerJohn Gittins
Coroner areaNorth Wales (East and Central)
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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) 

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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. 

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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. 

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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. 

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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. 

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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. 

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Dated 17th August 2023 

Signature   
Senior Coroner for North Wales (East and Central) 

Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN

Responses

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.

Response from Betsi Cadwaladr University Health Board (PDF)
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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