Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0526, written 8 Dec 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Dec 2023 |
|---|---|
| Reference | 2023-0526 |
| Deceased | Catherine Jones |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | Velindre NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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) 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 1 2 3 On the 11th of November 2016 an investigation was commenced into the death of Catherine Lisa Jones (DOB 24/11/80) who died at Wrexham Maelor Hospital on the 10th of November 2016. The conclusion of the inquest on the 8th of December 2023 and a narrative conclusion was recorded in the following terms : In 2012 scans identified an ovarian abnormality and as a result Catherine Jones underwent surgery in relation to the same. Subsequently a biopsy obtained during surgery was wrongly classified as benign and she had no follow up. In June 2016 it was identified that there was the development of a malignant disease process which would probably have been identified sooner if the 2013 sample had been correctly classified. Catherine underwent further surgery at that time but the presence of a soft tissue ovoid lesion was not identified either in surgery (or on a subsequent scan) and she did not undergo chemotherapy. Her cancer progressed and spread quickly due to its aggressive nature and whilst in hospital in October 2016 receiving treatment for complications arising from the same, she contracted a Clostridium Difficile infection which accelerated her deterioration. She died at the Wrexham Maelor Hospital on the 10th November 2016 as a result of widespread metastatic ovarian cancer contributed to by Pseudomembranous Colitis. 4 CIRCUMSTANCES OF THE DEATH As per the above narrative conclusion. 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 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. – It was indicated that for many departments within the health board, surgery was conducted on the basis of “pooled lists” and although evidence was given that the common practice of one of the surgeons was to ensure that they had some form of communication with the patient’s consultant prior to surgery (by phone and/or email), there was no evidence that this practice was part of an approved system of work which was documented within the health board’s protocols. In the absence of this being a part of an adopted practice and procedure guidance, I am concerned that there may be a lack of cohesive care and treatment for patients undergoing surgery and that future death may occur as a result. 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 6th February 2024. 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 12th December 2023 Signature Senior Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
2 responses 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: 06 February 2024 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 Catherine Lisa Jones I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 12 December 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching upon the death of Catherine Jones. I would like to begin with offering my deepest condolences to Ms Jones’ husband, family and loves ones. I also apologise unreservedly, on behalf of the Health Board, for the failings you identified in Mrs Jones’ care leading to her death in 2016. In the notice you highlighted your concerns that there may be a lack of cohesive care and treatment for patients undergoing surgery as a result of pooled surgical lists. Upon receiving the notice I asked my deputy executive medical director, to review and assess practice across the Health Board. This work has been completed and has identified the need to develop a clear and consistent policy for the entire organisation. Therefore, will be leading a task group to develop this policy which will involve all of our Integrated Health Communities and the relevant Regional Specialist Services. The group will meet monthly, starting in February 2024, and the work is estimated to be completed within six months. The new policy will be approved at the Planned Care Board to ensure operational and clinical ownership. This group will also oversee the progress of the task group. Implementation of this new policy will then be led by the medical directors for our divisions and reported back into the group. This new policy will achieve the aim of standardised practice across the Health Board. 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 Whilst we develop this new policy, to mitigate the risks, your notice has been shared with all our Integrated Health Communities and the relevant Regional Specialist Services so that local learning can be applied. I hope this letter offers you assurance on the action we will now take to ensure the concerns you raised are addressed and that changes are made to our clinical services. Once again, I offer my deepest condolences to the family and friends of Ms Jones for their loss. Yours sincerely Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro Executive Medical Director / Acting Deputy Chief Executive cc , Deputy Executive Medical Director , Deputy Director for Quality Governance
Eluned Morgan AS/MS
Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol
Minister for Health and Social Services
Mr John Gittins
Senior Coroner for North Wales (East and Central)
Coroner’s Office
County Hall
Wynnstay Road
Ruthin
Denbighshire, LL15 1YN
6 February 2024
Dear Mr Gittins,
Re: Regulation 28 Prevention of Future Deaths report – Catherine Lisa Jones
(deceased)
I am writing in response to a Regulation 28 Report to Prevent Future Deaths (the report),
which I received on 12 December 2023, following the conclusion of the inquest into the death
of Catherine Lisa Jones which occurred on 10 November 2016.
I would like to offer my sincere condolences to Ms Jones’ family on their sad loss.
In the report you raise a number of matters of concern, including the absence of cohesive
care and treatment for patients, and difficulties for clinicians in providing appropriate diagnosis
and treatment for patients, as a result of information not being readily accessible or available
within patients’ clinical records in the absence of electronic records.
You also referenced a letter of 18 October 2023 which the Deputy Minister for Mental Health
and Wellbeing and I jointly sent to you and Kate Robertson, the Senior Coroner North West
Wales, in response to matters of concern raised in an earlier Regulation 28 report following
an inquest into the death of RGG.
In that letter, we confirmed that we aim to implement a new electronic service joining up
clinical systems and data across all care sectors during the Summer of 2026. It is important
to note that the programme scope and timescales described in that letter relate to community
settings and would not be expected to directly impact on the circumstances described in the
report into Ms Jones’ death.
I am aware that at the inquest clinicians reported difficulties in accessing records. These I
believe related to in-hospital record sharing between teams, whilst our letter referenced a
previous report that highlighted concerns about the sharing of data in the community and
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Correspondence.Eluned.Morgan@gov.wales
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between different organisations. We recognise these are both serious issues which we are
committed to resolving.
The Welsh Government’s Digital and data strategy for health and social care in Wales sets
out our ambition to improve digital infrastructure and connectivity to deliver a secure and
sustainable foundation for seamless sharing of health and social care data across services
and sectors. This will be delivered by working with organisations, in particular Digital Health
and Care Wales, health boards and local authorities to improve how information is shared
and accessed across care provider settings.
I include below several examples in Wales where digital initiatives are being rolled out at pace
to effectively communicate and share information about the right patient, in the right place, at
the right time:
• The Welsh Nursing Care Record went live in 2021, allowing staff to record, share and
access patient information electronically across wards, hospital sites and health boards.
It has also standardised information collected about patients in hospitals, eliminating
variation. Patients and staff are able to move across services in Wales using this single
system, ensuring consistency and accuracy. Digital assessments involved in a patient’s
care journey are available to all clinical teams via the national digital patient record, the
Welsh Clinical Portal (WCP).
• The Digital Medicines Transformation Portfolio (DMTP) is making the prescribing,
dispensing and administration of medicines everywhere in Wales easier, safer, more
efficient and effective through digital transformation and functionality. It will result in a
shared medicines record for patients in Wales, ensuring that all medication information for
a patient is in one place, including current and previous medicines and in due course
patient-entered information on over-the-counter medicines (some of which can have a
reactionary effect on prescribed medications). Primary Care digital medicines was
announced in Rhyl at the end of November 2023 as being live in Wales and is now in the
process of being rolled out. All seven health boards (plus Velindre NHS Trust) are in the
process of planning for the implementation of secondary care digital medicines.
• Specifically for cancer care, the Cancer Informatics Programme (hosted by Digital Health
and Care Wales and being run on an all-Wales basis) is replacing the legacy CaNISC
software used for recording details of cancer care. The new Cancer Informatics Solution
(CIS) began implementation during 2022 and makes available a number of new clinical
records that can be viewed through the Welsh Clinical Portal. This includes an outpatient
oncology note, an inpatient oncology note, a radiotherapy treatment summary, a systemic
anti-cancer therapy treatment summary, and records of multi-disciplinary meetings.
Histopathology and radiology reports are also visible through the all-Wales care repository
for documents (WCRS) and an all-Wales repository for results and reports (WRRS), also
within the Welsh Clinical Portal. This means all the key clinical documents can be viewed
electronically in the Welsh Clinical Portal to support integrated cancer care across clinical
teams. It also includes functionality to notify the clinician of any new histopathology reports
they have requested, so that the clinician does not need to go into each individual patient
record to determine if there are outstanding results to review.
Therefore, histopathology test results are available for clinicians digitally. In line with 'Mission
3’ of the Digital and Data Strategy for Health and Social Care we will work with NHS Wales
to rationalise the number of systems that clinicians need to access to obtain the data needed
for patient care regardless of the setting they present at, making it simpler for them to identify
relevant data.
We recognise the need for investing in developments to digital shared care systems and
services to improve data sharing between settings and organisations across NHS and Social
Care sectors. Working closely with our partners, the Welsh Government will endeavour to
make every effort to encourage and support the implementation, and to increase the usage
and spread, of Digital Health and Care Record systems by health boards and local authorities.
Yours sincerely,
Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol
Minister for Health and Social Services
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