Prevention of Future Deaths reports · 2023

Jennifer Campbell

Regulation 28 report to prevent future deaths, reference 2023-0404, written 24 Oct 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report24 Oct 2023
Reference2023-0404
DeceasedJennifer Campbell
CoronerKate Robertson
Coroner areaNorth West Wales
CategoryHospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (2019 onwards)
Sourcejudiciary.uk record · original PDF
Responses published1

The report

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) 

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 3 March 2022 I commenced an investigation into the death of Jennifer Lydia 
Campbell (DOB 612/6/48) who died on 24 February 2022. The investigation concluded 
at the end of the inquest on 24 October 2023.  A narrative conclusion was recorded 
with the cause of death as:- 

1a Slower lobe pneumonia, biliary sepsis  
1b Obstructing gallstones 

Jennifer Lydia Campbell had an ultrasound scan of her abdomen on 25 October 2021 at 
the request of her GP following abnormal liver function tests, which showed gallstones. 
The GP referred her to gastroenterology on 28 October 2021. Following review, a 
referral was made by the gastroenterologist for Endoscopic retrograde 
cholangiopancreatography (ERCP) and this was sent to the endoscopy department on 3 
November 2021. The referral form was not received by the endoscopy department and 
the Endoscopic retrograde cholangiopancreatography (ERCP) did not occur. Jennifer 
Lydia Campbell became unwell on 22 February 2022 and was subsequently admitted 
into Ysbyty Gwynedd on 23 February 2022 where she was treated for severe infection 
due to obstructing gallstones and died on 24 February 2022. 

4 

CIRCUMSTANCES OF THE DEATH 

The circumstances of the death are as follows :- 

Jennifer Lydia Campbell was aged 73 years of age at the time of her death on 24 
February 2022. She had a recent past medical history of gallstones and previous kidney 
cancer. She underwent blood tests via her GP in October 2021 and in an appointment 

Coroner's Office, Shirehall Street, Caernarfon  

 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 on 11 October discussed her abnormal liver function test. On 25 October 2021 she 
underwent ultra sound of the abdomen which showed large gallstones. She was 
advised she needed a procedure. On 28 October 2022 a referral was sent by her GP to 
gastroenterology department, marked as routine. On 2 November 2021 the 
gastroneterologist referred Mrs Campbell directly for ERCP procedure and dictated a 
letter to her to explain this. A paper referral was completed as per procedure and sent 
to the endoscopy dept on 03 November 2021. There is no record of the referral form 
being received by endoscopy and it is not clear why it was not received or what had 
occurred to it. Jennifer Lydia Campbell received a copy of the letter from the 
Gastroenterology department dated 3 November 2021 confirming that ECRP was 
needed, and she had been put on the waiting list. On 21 February 2022 Mrs Campbell 
started to become unwell, she was in pain and suffering. On 23 February 2022 she 
attended the Emergency Department due to vomiting for 2 days and not being able to 
get out of bed. She was admitted but deteriorated and died on 24 February 2022 at 
Ysbyty Gwynedd from infection and pneumonia due to the obstructing gallstones. 

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  – 

a.  There was no evidence of any formal investigation having been undertaken into 
how the referral for ERCP became lost. It appears that only during the course of 
Inquest proceedings did the issue relating to the lost referral become known to 
the Health Board. Even once it became known to them in 2022 there was still no 
investigation undertaken. It is not understood at all which incidents that occur 
are  to  be  investigated.  I  have  issued  a  number  of  Prevention  of  Future  Death 
Reports  relating  to  investigations  and  governance  and  yet  these  concerns 
continue. I am not in any way satisfied that improvements have occurred.  

b.  Given that no investigation was conducted to understand how the issue may 

have occurred there has been no learning, change or improvement to ensure it 
is not repeated. I have been provided with no assurances in this regard. 

c.  There was no evidence that any audits had taken place to review whether any 

other patients’ referrals had become ‘lost’. 

d.  Matters relating to the ERCP which did not take place were identified by the 
Medical Examiners in their report dated 4 days after the deceased’s death. 
There was no evidence as to whether the Health Board had been made aware of 
the concerns therein and if so, what action they had undertaken as a result.  

Coroner's Office, Shirehall Street, Caernarfon  

 
 
 
 
 
 
 
 
 
 
 e.  Evidence was heard relating to electronic notes and referrals. Such referrals 
remain paper based and there is no indication as yet when these will be fully 
electronic. I am aware that this national strategy is ongoing but the time it is 
taking is putting patients’ lives at risk. 

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 19 December 2023. I, Kate Robertson, 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 have also sent a copy of this Report to 
information.  

, Health Minister, for her 

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 24 October 2023 

Signature   
Kate Robertson 
HM Senior Coroner for North West Wales 

Coroner's Office, Shirehall Street, Caernarfon

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 

Kate Robertson  
Senior Coroner for North West Wales  
HM Coroner’s Office 
Shirehall Street 
Caernarfon 
Gwynedd LL55 1SH 

Ein cyf / Our ref:  
Eichcyf / Your ref: 

Dyddiad / Date: 19 December 2023 

Dear Ms Robertson,  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
Jennifer Lydia Campbell 

I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 24 
October 2023, issued by yourself to Betsi Cadwaladr University Health Board, following 
the inquest touching upon the death of Jennifer Lydia Campbell.    

I would like to begin with offering my deepest condolences to the family and friends of 
Mrs Campbell.  

In the notice, you highlighted your concerns regarding the lack of an investigation and 
therefore subsequent learning, the absence of concerns from the medical examiner being 
acted  upon,  and  the  absence  of  a  strategy  for  introducing  electronic  patient  record 
systems.  

Turning to the first concern, we fully acknowledge that no incident was reported regarding 
the missing referral form and as such the incident review process did not take place. We 
are  taking  steps  to  ensure  staff  are  aware  of  the  need  to  report  an  incident  in  these 
situations through awareness and reminders. We are also undertaking a full review of the 
incident process in the Health Board, in co-design with our staff, and will introduce a new 
process and procedure for April 2024. This new process will include a revised training 
programme for staff.  

Following this incident, I can however confirm there has been learning and we have made 
improvements. A new standing operating procedure for all endoscopy referrals has been 
implemented  in  November  2023  to  ensure  all  paper  referrals  are  scanned  into  the 
endoscopy  email  inbox,  even  if  received  in  paper  format  by  the  endoscopy  booking 
clerks.  An  audit  has  been  completed  of  referral  forms  dating  01  October  2021  to  30 
November 2023 to ensure no other forms have been lost.  

In  relation  to  a  lack  of  action  on  concerns  from  the  medical  examiner,  whilst  I 
acknowledge  your  own  concerns,  the  Health  Board  only  received  the  report  from  the 
medical examiner on the day of the inquest as a result of your inquiries (and I understand 
you are aware of this issue at the inquest). The Senior Medical Examiner Officer for North 

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 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 Wales has confirmed no scrutiny document was created at the time of the death by them, 
and therefore the Health Board was not in receipt of the concerns they had. The medical 
examiner  service  is  independent  to  the  Health  Board  and  provided  nationally  by  NHS 
Wales Shared Services Partnership. We have reported this issue to them.  

We do however accept that we have improvements to be made to our own process, and 
the West Integrated Health Community have developed and implemented a process in 
November 2023 to ensure that any complaints, medical examiner reports, incidents and 
other  matters  are  adequately  reviewed  to  ensure  we  are  able  to  provide  patients  and 
families the best response and outcome, and to ensure lessons learnt are appropriate 
and shared.  

Our new incident process, and the accompanying training, will also stress the importance 
of triangulating information from all sources during an investigation.  

At an organisational level, our Mortality Review Team have developed and introduced a 
process whereby medical examiner forms are triaged upon receipt and will be sent to our 
clinical services and uploaded to our Datix quality management system within 2 weeks, 
ensuring they are available for access by those undertaking investigations. Following this 
triage, the team will also send a copy to the Patient Safety Team if anything is identified 
which may need to trigger the incident process.  This provides a further safety net and 
was introduced over the summer of 2023 as a result of your earlier concerns.  

In relation to electronic records, we are currently developing a strategic outline business 
case  for  an  Electronic  Patient  Record  (EPR)  system  in  conjunction  with  Welsh 
Government and Digital Health and Care Wales (DHCW). This business case will require 
significant investment and the Health Board hope to present it to Welsh Government in 
early 2024 and would expect significant time taken to secure approval. Once funds are 
secured,  the  timelines  for  delivering  such  a  significant  transformation  project,  as  is 
required in the case of the Health Board, will be at least three years. This is based on an 
independent  assessment made  of  our  business  need  in  terms  of people, practice and 
technology  by  Ethical  Healthcare  Consulting  who  have  been  assisting  us  with  this 
business case. 

As you have identified, there is not an electronic internal referrals system for endoscopy 
and therefore the Health Board is reliant on paper. A fully functioning EPR would address 
this and is the long term solution. 

The team at Ysbyty Gwynedd have put in place mitigations to ensure, as far as possible, 
no  further  referrals  are  misplaced.  This  includes  scanning  of  all  referrals  into  the 
endoscopy email inbox, even if they are hand delivered to the endoscopy booking clerks. 
Referrals are recorded onto the Welsh Patient Administration System (WPAS) as soon 
as they are received (including if a referral is rejected so that it will still show evidence 
that a referral was received and triaged). There is also agreement that no referrals will be 
given directly to the ERCP coordinator. If they receive one directly, they will hand to the 
booking clerks to be scanned and recorded as above.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In  parallel  with  the  operational  work  above,  the  Health  Board  are  working  with  Digital 
Health and Care Wales (DHCW) on the development of an electronic form as part of the 
Welsh Clinical Portal (WCP) that clinicians can use to do an internal referral specifically 
and exclusively for ERCP. It is not clear when this national work will be delivered and we 
are chasing them on it. 

I hope this letter sets out for you the actions we have taken, and will continue to take, to 
ensure the concerns you raised are being addressed.  

Once again, I offer my deepest condolences to the family and friends of Mrs Campbell 
for their loss. 

Yours sincerely 

Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro 
Executive Medical Director / Acting Deputy Chief Executive  

cc  

, Chief Digital and Information Officer  
, Deputy Director of Quality

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