Prevention of Future Deaths reports · 2023

Margaret Kelly

Regulation 28 report to prevent future deaths, reference 2023-0375, written 9 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Oct 2023
Reference2023-0375
DeceasedMargaret Kelly
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.

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John Gittins 
Senior Coroner for North Wales (East and Central) 

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 11th of April 2022 an investigation was commenced into the death of Margaret 
Gertrude Kelly (DOB 21/4/39) who died at Gian  Clwyd  Hospital on the 31st of March 
2022.  The conclusion of the inquest on the 5th  of October 2023 was by way of a 
narrative as detailed in paragraph 4 hereof with the cause of death being recorded as 
l(a) Multiorgan Failure (b) Intra-abdominal sepsis secondary to bowel perforation l(c) 
Abdominal wall hernia (operated) following hemicolectomy for adenocarcinoma of 
large bowel 

CIRCUMSTANCES OF THE DEATH 
On the 28th of March 2022, the deceased underwent an elective surgical hernia repair 
during which it is probable that her bowel became damaged. The following day she was 
in pain and attended the Emergency Department at Gian Clwyd Hospital as she had 
been unable to get an answer from the telephone number which she'd been  given. She 
was not seen by a surgical doctor for several hours and  by the following morning, the 
30th of March, when her condition had deteriorated considerably, further emergency 
surgery was undertaken to repair the bowel perforation. As a result of there being 
several missed opportunities to optimize her care and treatment, Mrs Kelly no longer 
had the resilience to recover from this procedure and she died at Gian Clwyd  Hospital 
on the afternoon of the 31st of March 2022. 

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.  -

Evidence was given at the inquest that when the deceased attended the emergency 
department it was at level 4 escalation (the highest level which they would escalate to), 

 
 
 
 that this was far from unusual and that between March 2022 and the present day, the 
department would usually be operating between levels. 3 & 4. 

I am concerned that the pressure on clinicians and other staff is  unsustainable and that 
delays in treatment will result in deaths. I do not consider that the operating practices 
within the department are a direct cause for concern (and as a result I do not require 
hearing the views of any clinicians in respect thereof), however I am concerned that 
insufficient or ineffective strategic planning and support is being undertaken and I 
would therefore wish to hear from those responsible at an executive/managerial level 
as to the steps which are being taken to reduce pressures within the department at 
Gian Clwyd. 

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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 4th December 2023. I, John Gittins, 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 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 9th October 2023 

~ c ; -~  
Signature 
Senior Coroner for North Wales (East and Central)

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 Unviersity 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: 04 December 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 
Margaret Gertrude Kelly  

I  write  in  response  to  the  Regulation  28  Report  to  Prevent  Future  Deaths  dated  09 
October 2023, issued by yourself to Betsi Cadwaladr University Health Board, following 
the inquest touching upon the death of Mrs Margaret Kelly.  

I would like to begin by offering my deepest condolences to the family and friends of Mrs 
Kelly for their loss.  

In  the  Notice,  you  highlighted  your  concerns  about  unsustainable  pressure  on  clinical 
staff at the Emergency Department at Ysbyty Glan Clwyd, and you wanted to know what 
action executive and senior management is taking to reduce those pressures.  

The first part of our response addresses what is being done by the Central Integrated 
Health Community (IHC) to support the department. The Central IHC is the component 
of the Health Board responsible for planning, managing and improving integrated primary, 
community and secondary health services across Denbighshire and Conwy.  

The Central IHC Leadership Team are working with our operational and clinical teams to 
ensure that we are providing the necessary support required in order to be able to provide 
our  population  with  a  service  that  supports  a  reduction  in  unscheduled  care  hospital 
attendances  and  ensure  we  improve  the  experience  of  our  residents  requiring  urgent 
care.  

Urgent & emergency care provision is one of the main priorities for the Central IHC and 
requires significant support and focus to deliver improvements. We have recognised that 
a  programme  management  approach  is  required,  and  have  established  a  dedicated 
project team to support the development and delivery of our improvement work related 
to urgent and emergency care. This additional capacity is vital in supporting operational 
teams to drive the programmes forward at pace and embed the change as we go.  

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 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 Our  Urgent  and  Emergency  Care  (UEC)  Improvement  Programme  incorporates  the 
delivery against our Special Measures priorities and the National Six Goals for Urgent 
and  Emergency  Care,  taking  a  whole  system  approach  which  includes  strengthening 
primary  care,  collaborating  with  our  partners  in  local  authority  and  WAST  (the  Welsh 
Ambulance Service Trust).  

Our focus for the coming months (and beyond) is on supporting and bolstering our ability 
to deliver business as usual services, by reviewing how we deliver those services, and 
by moving existing resource to either support or work in a different way. 

The  following  projects  and  work  streams  are  underway  to  ensure  we  have  a  robust 
solution  put  in  place  to  manage  the  emergency  department  pressures  at  Ysbyty  Glan 
Clwyd: 

  The  8  Steps  Project  is  aiming  to  improve  each  of  the  steps  that  patients  take 
through their ED journey, creating efficiencies and therefore reducing the waiting 
time  within  the  ED.  Performance  is  being  continuously  monitored  through  a 
dashboard and to identify improvements to working practice. The 8 steps include:  

1.  Awaiting triage  
2.  Awaiting doctor  
3.  Awaiting ED plan  
4.  Awaiting ED decision  
5.  Awaiting specialty review  
6.  Awaiting specialty outcome  
7.  Senior decision to admit  
8.  Bed allocation  

Daily focus on 8 steps to ED performance is undertaken in morning huddles with 
clinical,  nursing  and  operational  leads.  The  NHS  Wales  national  improvement 
service, Improvement Cymru, are working with ED and site team from October to 
add challenge and support into the daily rhythm and flow 

  Work is underway to improve the YGC acute medical model. Operational teams 
are developing the model, rota and working patterns to support this. The objectives 
of the new model are to deliver timely patient care, provide senior decision-making 
support  to  the  ED,  and  ensuring  patients  are  cared  for  by  the  best  medical 
specialty and in the right place. 

  Our Operational Management Team are working on two key areas around SDEC 
improvement:  Improving  the  IT  systems  used  by  staff  and  using  new  telephony 
systems to support more referrals from GPs and WAST into the SDEC service. 

  Developing a more efficient board round system will expedite patients home in a 
timely  manner,  improving  patient  flow  and  relieving  pressures  upstream  in  the 
emergency department. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   We are currently finalising plans to return the GP Out of Hours Service to the YGC. 
This is in line with Peer Review recommendations and will ensure co-located GP 
services  to  ED for nearly  70% of  the  week  (6.30pm-8am  Mon  –  Fri and  all day 
Saturday  and  Sunday).  We  are  currently  working  with  operational  leads  to 
implement this provision before winter pressures this year. Patients presenting in 
YGC ED with primary care presentations during week day hours will be advised 
how they can access local primary  care services (GP / Optometry / Community 
Pharmacy / Dental).  

  The IHC have re-established fortnightly strategic meetings with WAST to review 
demand and conveyances and actions that can be taken to reduce demand. 

  On  12  October  2023,  IHC  Directors  presented  current  ambulance  performance 
data  at  the  monthly  ED  Governance  Meeting  to  review  actions  required  and 
identify  the  support  needed  to  achieve  zero  tolerance  of  4  Hour  Ambulance 
Handover from 1st November 2023. 

  An  ED  rota  review,  including  skill  mix  is  scheduled  for  November  as  we  have 
identified doctor shortages compared to attendances on Monday’s and Tuesday’s 
(two busiest days). 

  A  test  of  a  Monday  to  Friday  9am-5pm  ‘see  and  treat’  model  will  also  be 
undertaken  during  November  for  staff  learning  and  to  evaluate  impact  on  non-
admitted performance and de-compressing ED. 

You will be aware of other work from our responses earlier in the year about ambulance 
handover delays, as part of the National Six Goals Programme, and I have not repeated 
that wider work here but I would wish to draw the link to that programme.  

In relation to the main point of your Notice, regarding executive support, it is important for 
me to highlight the current position of the Health Board.  

As you will know, the Health Board has been placed into Special Measures in February 
2023  and  since  then,  a  new  Interim  Chair  has  been  appointed,  new  Independent 
Members of the board are in place, and within the last few weeks, a new permanent Chief 
Executive has been appointed. A new interim Executive Director of Operations has also 
been appointed.  

As  part  of  our  Special  Measures  programme,  a  number  of  Independent  Reviews  are 
underway into core aspects of the Health Board’s governance, planning and leadership. 
These reviews will help us shape how the Health Board will change in the future.  

The  Special  Measures  programme  is  organised  into  three  phases  –  Stabilisation, 
Standardisation and Sustainability. We are currently at the Stabilisation phase and are 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 taking  action  to  strengthen  planning,  leadership  and  governance  across  the  Health 
Board.  This  work  is  being  done  against  the  requirement  from  Welsh  Government  to 
ensure financial savings are being delivered.  

As an Executive Team, we are fully committed to supporting the ED through the Central 
IHC  to  develop  and  deliver  its  improvement  plans,  which  are  outlined  above.  We  will 
scrutinise those plans and performance, and provide support.  

The ED at Ysbyty Glan Clwyd continues to face significant pressure. You will be aware 
that  Healthcare  Inspectorate  Wales  designated  it  a  Service  Requiring  Significant 
Improvement.  We  have  supported  the  ED  to  develop  and  deliver  considerable 
improvement plans in response to the three HIW inspections since February 2022, and 
during the summer of 2023 we supported a “mock inspection” (called a Quality Check) to 
provide an objective progress update. Our Executive Director of Nursing and Midwifery 
is overseeing the continuing actions arising from this process.  

We will continue to support the ED and we expect a further HIW inspection in the near 
future, which will provide a further independent review of progress during which we hope 
to see it deescalated as a Service Requiring Significant Improvement.  

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 Mrs Kelly 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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