Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0116, written 1 Mar 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Mar 2024 |
|---|---|
| Reference | 2024-0116 |
| Deceased | Jennifer Trigger |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| 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.
John Adrian Gittins Senior Coroner for North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW. CORONER 1 I am John Adrian Gittins, Senior 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 the 28th of September 2020 I commenced an investigation into the death of Jennifer Ann Trigger (DOB 27.12.48 DOD 31.1.20). The investigation concluded at the end of the inquest on the 29th of February 2024. The cause of death was recorded as being due to 1(a) Extensive intra-cranial bleed 2. Warfarin Therapy and the conclusion of the inquest was that of natural causes contributed by neglect. 4 CIRCUMSTANCES OF THE DEATH On the evening of the 29th of January 2020, the deceased was admitted to the Wrexham Maelor Hospital after becoming unwell. It was established that she had suffered an acute stroke and as she was on warfarin for a pre-existing condition , she was appropriately prescribed beriplex by way of treatment to reduce the risk of an extension of the bleed in her brain. Although this was prescribed at around 20.45 it was not administered until 07.35 the following morning despite it being a time critical treatment. By this time there had been an extension of the bleed with associated oedema and her condition had deteriorated significantly. Despite medical intervention and treatment in intensive care she was verified deceased at 18.30 on the 31st of January 2020 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed the following matter 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 MATTER OF CONCERN is as follows. – There was a miscommunication or misunderstanding when a ward nurse bleeped a junior doctor with a view to action being taken in relation to the administration of the beriplex infusion. This resulted in a delay in the doctor attending as she did not prioritise a task which was time critical and the subsequent delays resulted in an unrecoverable deterioration in the patient’s condition. Evidence was received in the course of the inquest that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN as to work requirements and hence impacted upon prioritisation of tasks and therefore potential delays, the effects of which (as in this case) could be catastrophic in terms of patient safety. Evidence was also given that alternative systems existed that had the potential for mitigating or eliminating such risk by way of the electronic transfer of information and requests to doctors. 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 by 26th of April 2024 I, 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 1st March 2024 Signature Senior 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: 26 April 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 Jennifer Ann Trigger I write in response to the Regulation 28 Report to Prevent Future Deaths dated 01 March 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Mrs Jennifer Trigger. I would like to begin by offering my deepest condolences to the family and friends of Mrs Trigger and on behalf of the Health Board I apologise to them for the failures that were identified during the inquest. In the notice, you highlighted your concerns that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding leading to a patient safety risk. In response, I asked our Digital, Data and Technology Department to provide me with assurance on their improvement plans, which I have summarised below. The Health Board has been working on a paging system replacement and upgrade project for 12 months. The project involves the replacement of existing on-site paging at Ysbyty Gwynedd in Bangor with an integrated critical messaging service, as part of an overall solution with Ysbyty Glan Clwyd in Bodelwyddan and Wrexham Maelor Hospital. This includes a technical refresh to upgrade the existing Multitone iMessage critical messaging services across Ysbyty Glan Clwyd and Wrexham Maelor Hospital and to integrate services at Ysbyty Gwynedd. Ysbyty Glan Clwyd and Wrexham Maelor Hospital were upgraded on 20 March 2024, and the go live at Ysbyty Gwynedd will be in approximately 4 weeks. 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 Paging systems have always been used (and still are) for critical paging for 2222 emergency and urgent calls. It is a proven and reliable system for getting hold of and delivering fast bleeps to those critical teams who need to respond to an emergency. The new Multitone iMessage critical messaging system will improve resilience and will provide standardisation across the 3 general hospitals and switchboards, and will allow for inter-site paging and cross cover arrangements. The ongoing improvements in our systems will improve on site communication for staff to support patient referral, transfers, treatment and discharge and improve efficiencies. A number of technical options are being tested to achieve this, with the testing informing a decision on the specific future solution. These options include WiFi telephones (being tested with ward managers and matrons at Ysbyty Gwynedd) and smart phone devices with the Microsoft Teams and Cisco apps to enable calls and instant messaging through our network (being tested with 34 medical staff in Ysbyty Gwynedd). As with any new technology, it is vital we test the options with front line clinicians to inform the best solution and to ensure patient safety. We also recognise the issue of communicating important clinical and patient safety information and tasks goes beyond technology, and to that end we will be issuing a Safety Alert across the organisation to highlight the learning from this case. This alert will be issued by the end of April 2024. We have also taken other action to improve patient safety whilst a technical solution is implemented. At Wrexham Maelor Hospital, the use of the bleep system out of hours has been restricted to four key areas to reduce the load and distraction on junior doctors. These four areas are deteriorating patients, deceased patients, fallen patients and time critical medication. All other tasks now wait for the junior doctor to circulate the wards. The site have also mandated 3pm ward huddles across all wards so that junior doctors and nursing teams can assess what tasks need doing in the 2 hours before the end of the in hours working day, reducing the out of hours workload and urgency. These improvement have been shared with the medical directors for our other general hospital sites. I hope this letter sets out for you the actions we are taking to ensure the concerns you raised are being addressed. We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful. Once again, I offer my deepest condolences to the family and friends of Mrs Trigger for their loss and I reiterate our apologies to them for the concerns identified at inquest. Yours sincerely Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro Executive Medical Director / Acting Deputy Chief Executive cc , Deputy Director of Quality
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