Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0471, written 24 Nov 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 Nov 2023 |
|---|---|
| Reference | 2023-0471 |
| Deceased | Hazel Pearson |
| Coroner | Kate Robertson |
| Coroner area | North Wales (East and Central) |
| Category | Care Home Health 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.
Kate Sutherland
Assistant Coroner for North Wales (East and Central)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Betsi Cadwaladr University Local Health Board
1
CORONER
I am Kate Robertson, Assistant Coroner for North Wales (East and Central)
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 6 December 2021 an investigation was commenced into the death of Hazel Pearson
(DOB 28/6/42) who died on 30 November 2021. The investigation concluded at the end
of the inquest on 23 November 2023. The conclusion of the inquest was a narrative
conclusion as follows :
Misadventure contributed to by neglect
4
CIRCUMSTANCES OF THE DEATH
The circumstances of the death are as follows :
Hazel Pearson was admitted into Ysbyty Maelor hospital on 20/8/21 having spent some
time at a care home and community hospital before returning to Ysbyty Maelor hospital
on 23/11/21. She had known coeliac disease which was recorded on her medical records.
Her family had repeatedly informed staff about her coeliac disease. On 26/11/21 she was
offered and consumed Weetabix probably believing it was a gluten free equivalent. This
caused her to vomit, aspirate, suffer significant oxygenation and subsequent respiratory
deterioration which then led to her death from aspiration pneumonia. She died on
30/11/21 at Ysbyty Maelor, Wrexham.
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving rise to concern.
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
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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: –
1. Despite the deceased passing away just shy of 2 years ago, there have been
inadequate improvements to manage patients with food intolerances and
allergies. The Health Board has been working with other organisations in Wales
to create an e-learning module and implement the use of red wrist bands for
food intolerances / allergies, but this has taken far too long. The e-learning
training module was uploaded to BCUHB system the day prior to the Inquest. It
is strongly suspected that this was due to the impending Inquest.
2. The Health Board has not investigated the incident at all. A Medical Examiner
Report was prepared following the death in November 2021 highlighting the
ingestion of gluten in a coeliac patient. I have raised and continue to raise a
number of concerns around the inadequacy of governance and poor
investigation processes.
3. There were other incidences of gluten ingestion at Ysbyty Maelor and Deeside
Community Hospital. On the at least 4 occasions at Deeside Community Hospital
there were no Datix reports completed at the time. I was provided with no
evidence that additional training, refresher training or induction training deals
with when such reports should be made. I cannot be satisfied and reassured
that all staff are aware of when to make a Datix report and how to complete
this.
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 18 January 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 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
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
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your response, about the release or the publication of your response by the Chief
Coroner.
9
Dated 23 November 2023
Signature
Assistant 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: 18 January 2024 Kate Robertson HM Assistant Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Dear Ms Robertson, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Hazel Pearson I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 23 November 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching upon the death of Hazel Pearson. I would like to begin with offering my deepest condolences to the family and friends of Mrs Pearson. In the notice you highlighted your concerns regarding inadequate improvements to manage patients with food intolerances and allergies, concerns around the inadequacy of governance and poor investigation processes, and concern that staff may not be aware of when to make a Datix report and how to complete this. On the first concern, I fully acknowledge that the delays in rolling out the improvements to managing patients with food intolerance and allergies were not acceptable. In hindsight, waiting for an all-Wales training package to be agreed was not the correct course of action and some local in-house training should have been developed. The adoption of an all-Wales approach was to ensure consistency of the message and also as a means of accurately recording compliance rates through the national system, the Electronic Staff Record (ESR), which allows reports to be processed on a monthly basis and appropriate action taken to ensure uptake if training does not meet expectations. Other forms of training were considered at the time but there was not a robust mechanism in place to record those. In relation to your concern that the training was launched only due to the impending inquest, I can advise the Health Board had been pushing at an all-Wales level some 6 months ahead of the inquest, but I appreciate how that may have looked just before the inquest date. Following the inquest, further meetings have taken place in December 2023 to communicate the roll out of the red wrist bands, which has now happened via the BetsiNet intranet page accessible by all staff and the training is live, with agreed staff groups being 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 assigned to undertake this training. This will be mandated for them and will automatically appear on their ESR compliance page. Those staff will be all frontline staff who have an involvement in meal provision, with catering staff having an advanced level of training, which is already in place. In addition, agency staff and students will be required to undertake the training and this has been communicated with the agencies and local universities in January 2024. Training for volunteers is also being reviewed in January 2024, and the necessary training links and materials will be made available for the voluntary staff in February 2024. I have enclosed a copy of the communication to all staff via our BetsiNet intranet. The documents that underpinned the use of red wrist bands were all agreed and signed off through the relevant governance groups 8-9 months from the task and finish group being established. It is acknowledged that there were gaps in the escalation process from the Make it Safe incident review meetings to the Improving Nutrition, Catering and Hydration Standards (INCHS) Group and the governance structure underneath that group has been reviewed and changes are being made to ensure escalation processes are robust and timely. Compliance with training uptake will be reviewed initially at the end of February 2024 by the chair of INCHS and thereafter through the INCHS quarterly meetings, with the next one of those in March 2024. Appropriate action will be taken if uptake is lower than anticipated or slower than required through the relevant service leadership teams. To support ongoing improvement, we are also exploring how the Health Board can access expert advice in relation to compliance. Wrexham Council, acting as the Primary Authority for North Wales, have been providing some formal guidance to the Health Board in relation to food safety, specifically food hygiene. The same arrangement for food standards, where food allergens sits, is not in place. The Health Board are considering commissioning this support going forward and will require some funding to support this. The Local Authority have been providing some advice to the Health Board but not in any formal capacity. On the second and third points around incident reporting and investigations, I know we have written to you recently regarding these points. To summarise our earlier responses, as you know we are 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 on conducting investigations. A revised training programme for incident reporting is in place for all staff with dates confirmed across North Wales for the next quarter alongside “how to” guides and videos for staff to access at any time via the BetsiNet intranet. 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 Pearson for their loss. Yours sincerely Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro Executive Medical Director / Acting Deputy Chief Executive cc , Acting Executive Director of Therapies and Health Sciences , Deputy Director of Quality Appendix 1 – Screenshot of BetsiNet staff communication Appendix 2 – Screenshot of BetsiNet staff communication
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