Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0177, written 27 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 | 27 Mar 2024 |
|---|---|
| Reference | 2024-0177 |
| Deceased | Maureen Owens |
| 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 15th of August 2023 I commenced an investigation into the death of Maureen Elizabeth Owens (DOB 28.2.43 DOD 9.12.22). The investigation concluded at the end of the inquest on the 20th of March 2024. The cause of death was recorded as being due to 1(a) Multiorgan Failure 1(b) Bilateral Femoral Thrombosis (operated) 1(c) Peripheral and Central Vascular Disease and the conclusion of the inquest was by way of a narrative in the following terms : The death was due to natural causes, contributed to by operational delays as a result of which the deceased was not afforded the timely care and treatment which may have optimised the prospects of a full recovery 4 CIRCUMSTANCES OF THE DEATH On the 6th of December 2022, whilst a patient at the Maelor Hospital Wrexham, the deceased developed a condition which required urgent vascular surgery, however her transfer for this procedure was delayed and despite subsequent surgical intervention, she deteriorated post-operatively and died at Glan Clwyd Hospital on the 9th of December 2022. 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. – An investigation by the Health Board indicated that the transport request for urgent transfer for vascular surgery should have been booked by the ward with the Adult Critical Care Service Cymru (ACCTS) and not WAST and evidence was received in the course of the inquest which suggests that there is inadequate knowledge of the use of ACCTS and its operation across the whole of the Health Board, including clinical site managers as well as clinicians and nursing staff. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN 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 28th of May 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 2nd April 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 Ein cyf / Our ref: Eichcyf / Your ref: Dyddiad / Date: 28 May 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 Maureen Elizabeth Owens I write in response to the Regulation 28 Report to Prevent Future Deaths dated 02 April 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Mrs Maureen Owens. I would like to begin by offering my deepest condolences to the family and friends of Mrs Owens. In the notice, you highlighted your concerns that that there is inadequate knowledge of the use of the Adult Critical Care Transfer Service (ACCTS) and its operation across the whole of the Health Board, including clinical site managers as well as clinicians and nursing staff. Following the inquest, the Emergency Medical Retrieval and Transfer Service (EMRTS) , EMRTS National have examined the patient records and Director, has written to me with their findings. They confirm that it is correct that the ACCTS were not contacted about the transfer of Mrs Owens, and from their review confirm Mrs Owens did not meet the current criteria for ACCTS referral or transfer since the proposed transfer was a ward to ward transfer and there were no critical care needs identified. The ACCTS service is currently only commissioned to transfer patients with critical care requirements. Therefore, the referral was correctly made to the Welsh Ambulance Service Trust and the clinical urgency of the transfer should have determined the speed of response and transfer. As you know, significant work is already underway to improve Urgent and Emergency Care as part of the Welsh Government Six Goals Programme as we have detailed in other responses to you previously. Specifically in relation to these concerns about staff 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 awareness of the transfer procedures, I asked our Associate Director of Urgent and Emergency Care to develop improvement actions, which I have summarised below. Whilst there is a confirmed process in place for requesting immediate transfers that is utilised effectively on a daily basis across North Wales, in response to your notice we have identified further learning and improvement is required to support all our staff and as such, we have agreed actions for implementation: No. Action/Objective Re-share with all Integrated Health Communities (IHCs) the agreed transfer process and seek confirmation from them this has been cascaded All acute sites to confirm site management teams as the single point of contact for emergency transfers from their respective sites Health Board wide system focus on service provision required for intra-hospital transfers for specialties between Hub and spoke sites – a workshop date will be finalised (working closely with national commissioners) Delivery Date 13/05/2024 (Complete) 10/06/2024 01/08/2024 Review the Patient Transfer Procedure (NU19) – this work is already underway led by a Head of Nursing and the Head of Patient Safety Develop a monitoring process for transfers/repatriations in line with the All-Wales repatriation process as part of the Six Goals Programme for Urgent and Emergency Care 01/08/2024 01/09/2024 1. 2. 3. 4. 5. Delivery against the above actions will be overseen by the Associate Director for Urgent and Emergency Care who will provide assurance to the Urgent and Emergency Care Programme Group that the above actions have been delivered. I hope this letter sets out for you the actions that 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 Owens for their loss. Yours sincerely Cyfarwyddwr Meddygol Gweithredol / Dirprwy Prif Weithredwr Dros Dro Executive Medical Director / Acting Deputy Chief Executive cc , Deputy Director of Quality
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.