Prevention of Future Deaths reports · 2023
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 report | 24 Oct 2023 |
|---|---|
| Reference | 2023-0404 |
| Deceased | Jennifer Campbell |
| Coroner | Kate Robertson |
| Coroner area | North West Wales |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Wales prevention of future deaths reports (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) 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
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 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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