Thomas Ithell

Bloc 5, Llys Carlton, Parc BusnesLlanelwy, 
Llanelwy, LL17 0JG 

---------------------------------- 

Block 5, Carlton Court, St Asaph Business 
Park, St Asaph, LL17 0JG 

Dyddiad / Date: 18 March 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 
Thomas Grenville Hammersley Ithell 

I am writing in response to the Regulation 28 Report to Prevent Future Deaths dated 22 
January 2024, issued by yourself to Betsi Cadwaladr University Health Board, following 
the inquest touching upon the death of Mr Thomas Ithell, who sadly died on 20 November 
2022.    

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

In the notice you highlighted your concerns as follows: 

  There was no Datix raised by anyone when the error (Mr Ithell being lost to follow 
up) was identified, either at the time of the appointment on 22 October 2022 when 
the error was identified or at any point thereafter;  

  There has been no investigation by the Health Board into how Mr Ithell came lost 

for follow up after his appointment on 5 November 2021;  

  There have been no assurances as to what, if any, changes and learning have 

been identified other than a tracking system for PSA monitoring;  

  Evidence was heard at the Inquest that time restraints on hospital staff had meant 

that Datix was not completed and that the system was not user-friendly.   

I will firstly address the concerns around incident reporting and investigation including the 
Datix system (points 1, 2 and 4 from above).  

I can confirm that an Incident Report has now been raised in regards to the error identified 
and a  Make  it  Safe  Rapid  Review  was  undertaken. This  review  was  completed  on  05 
March 2023. A decision was made to conduct a full investigation and this is underway at 
present. The incident has been confirmed as a Nationally Reportable Incident (NRI). The 
investigation report is due to be completed by 09 May 2024 and will include a full action 
plan to address any areas of learning. 

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 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 I  am  aware  you  have  raised  your  concerns  with  regards  to  incident  reporting  and 
management previously. Since those earlier concerns, a revised training programme has 
been put in place for our Datix incident reporting system. This includes training offered 
by our Quality Systems Team on the Datix system twice monthly, training specifically on 
incident reporting and reviewing delivered by our Patient Safety Team weekly, and local 
training  delivered  by  our  locally  based  quality  teams  (in  our  East  Integrated  Health 
Community for example, there are weekly dates offered). This range of training means 
there is a mix of opportunities for staff to access training. A number of training videos and 
“how to guides” are available on our staff intranet.  

Another area of concern you have raised previously, and which is relevant here, is the 
flow  of  information  from  the  Independent  Medical  Examiner  Service  into  our  incident 
process. I fully acknowledge this is an areas of concern. As a result of the concerns, the 
Mortality Review Team have met with the Patient Safety Team and changes are being 
made. These changes mean that the Mortality Review Team will review every new form 
with  concerns  received  from  the  Medical  Examiner  Services  to  identify  if  an  existing 
incident  review  is  underway  in  which  case  the  records  in  Datix  will  be  linked  and  the 
incident reviewer and divisional leadership team will be notified. If no incident review is 
underway, the Mortality Review Team will take the concerns to the daily incident review 
meeting led by the Patient Safety Team at which time a decision can be made to trigger 
the  incident  process.  This  new  process  is  commencing  in  March  2024  and  will  be 
embedded  fully  into  our  practice  in  the  coming  months,  which  will  ensure  the  flow  of 
information from the Medical Examiner into the incident process. 

I can also advise that the Patient Safety Team have reviewed the incident process and 
intend to make changes to that process from April 2024. The team have been working 
with  services  to  co-design  the  changes  taking  into  account  feedback  from  front  line 
clinicians and looking at best practice across Wales. Over the coming months, we plan 
further reviews  into  this  process  with  support from  the  NHS Wales  National Executive 
Quality Team.  

In respect of clinical time, our staff do face significant challenges in balancing all of the 
required duties whilst providing patient centred care. We are fully mindful of the pressures 
they face and we will always support them to ensure safety critical tasks are completed. 
This includes reporting incidents on the Datix system.  

The Datix system is a national system, officially known as the Once for Wales Concerns 
Management System. It is designed and managed nationally in a service hosted by the 
Welsh  Risk  Pool,  part  of  the  NHS  Wales  Shared  Services  Partnership.  The  current 
version  of  the  system  was  implemented  in  April  2022.  The  move  to  a  single,  national 
system was an expectation set by Welsh Government. Therefore every member of staff 
across NHS Wales, in every Health Board and Trust, uses this system.  

The design and development of the system has been led an on all-Wales basis and has 
clinical and non-clinical staff input. Each module, such as the incident module, is aligned 
to  a  national  network  who  lead  on  the  design  and  development  of  that  module  and 

 
 
 
 
 
 
 
 
 
 
 
 
 
 facilitate any requests for change and enhancement made by staff and services across 
Wales. 

Within the Health Board, in November 2023, we formed a new Quality Systems Group to 
provide  greater  oversight  of  our  quality  systems  in  a  more  integrated  approach.  This 
group’s  remit  includes  collecting,  assessing  and  acting  upon  user  feedback.  Over  the 
coming months we will be conducting a survey of our staff experiences in using the Datix 
system  and  we  will  use  these  findings  to  make  recommendations  nationally  on 
improvements or enhancements to the system (recognising any changes we suggest will 
be subject to all-Wales agreement).  

I will now address point 3 of your concerns, regarding PSA monitoring.  

Following  the  Make  it  Safe  Rapid  Review,  a  number  of  immediate  actions  have  been 
agreed. These actions have included  validating patients awaiting a clinical decision on 
the pathway and follow up waiting list.  

Awareness of the pathway has also been raised with other specialities.  

A suggestion has also been raised with the Digital, Data and Technology Department to 
consider whether an alert can be built into the electronic patient administration system to 
identify patients without a follow up appointment.  

As mentioned earlier, a full investigation is underway and we expect that a detailed action 
plan  will  be  developed  in  response  to  its  findings.  This  report  and  action  plan  will  be 
subject to scrutiny by the East Integrated Health Community directors and will receive 
final approval and sign off by a Clinical Executive Director.  

I hope this letter provides you with the assurance you need that actions have been taken 
– and assurance that further investigation is underway.  

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

Yours sincerely 

 BMedSci BMBS MRCS DOHNS GDL LLM FRCEM FFMLM MBA 

Dirprwy Gyfarwyddwr Meddygol Gweithredol 
Deputy Executive Medical Director 

cc  

, Executive Medical Director  
, Executive Director of Nursing and Midwifery  

, Deputy Director of Quality