Clara Winter

GRAEME HUGHES

HIS MAJESTY’S
SENIOR CORONER

SOUTH WALES CENTRAL
CORONER AREA

CORONER’S OFFICE

THE OLD COURTHOUSE

COURTHOUSE STREET

PONTYPRIDD

CF37 1JW

Telephone:

Email:

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

The Chief Executive, Cwm Taf Morgannwg University Health Board

CORONER

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I am Kerrie Burge, Assistant Coroner for the coroner area of South Wales 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

On 12th. December 2022, 1 commenced an investigation into the death of Clara Novella
Winter, aged 77. The investigation concluded at the end of the inquest on 17th. May 2024.
At the conclusion of the inquest, the medical cause of death was established as

1a Perforated incarcerated ischaemic bowel
1b Intra abdominal adhesions in the setting of elective cholecystectomy (operated on
14/11/2022) and previous pelvic surgery

My conclusions were that Clara Novella Winter died at Prince Charles Hospital on 19th.
November 2022 as a result of a perforated incarcerated ischaemic bowel.

I reached a narrative conclusion that following routine and uneventful surgery to remove
her gall bladder, Mrs. Winter's bowel became inflamed and resulted in complications with
her existing hernia, including further adhesions, incarceration of the bowel, ischaemia and
a bowel perforation. Emergency surgery was carried out to repair this but sadly Mrs. Winter
was unable to recover.

Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW

 CIRCUMSTANCES OF THE DEATH

Mrs. Winter was admitted to hospital on 14th. November 2022 for an elective laparoscopic
cholecystectomy. She had undergone surgery some years ago which had resulted in
complications, including an irreducible hernia and adhesions. Her condition deteriorated
the following day, reaching crisis point at around 23:00. Subsequent emergency surgery
revealed that whilst the upper abdomen area was normal, the existing hernia had changed,
an ischaemic patch had developed along with a bowel perforation. A right hemi colectomy
with side to side anastomosis was necessary. Mrs. Winter survived the surgery but later
died.

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CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters 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 MATTERS OF CONCERN are as follows.

Following Mrs. Winter’s death, her family raised concerns about her post operative care. I
did not find that her post operative care more than minimally contributed to Mrs. Winter’s
death. However, following an internal review:

1.  The Health Board accepted that significant learning was required by staff regarding
timeliness of escalation and maintenance of fluid balance charts and recommended
that all registered nurses from surgical wards should attend an ‘Acutely Unwell'
study day, before the end of 2023.

2.  This ‘significant learning’ has not been fully rolled out due to resourcing issues. No
completion date could be provided to me because the training is not considered to
be compulsory.
ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you and your
organisation have the power to take such action.

YOUR RESPONSE

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Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW

 You are under a duty to respond to this report within 56 days of the date of this report,
namely by 22nd. July 2024. 1, 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.

COPIES and PUBLICATION

I have sent a copy of my report to family who may find it useful or of interest.

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.

28 May 2024

SIGNED:

Kerrie Burge Assistant Coroner for South Wales Central Coroner Area

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Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW

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Cyfeiriad Dychwelyd/ Return Address:
Bwrdd lechyd Prifysgol
Cwm  Taf  Morgannwg
Pencadlys
Parc Navigation,
Abercynon
CF45 4SN

Cwm  Taf  Morgannwg
University Health Board
Headquarters
Navigation Park
Abercynon
CF45 4SN

Ff6n/Tel:

Eich cyf/Your Ref:
Ein cyf/Our Ref:
Ebost Email:
Dyddiad/Date:

22 July  2024

Private & Confidential
Kerrie Burge
Assistant Coroner
South Wales Central Coroner Area
Coroner’s Office
The Old Courthouse
Courthouse Street
Pontypridd
CF37 1JW

Dear Ms Burge,

I  am  writing in  response to  a  Regulation  28:  Report to  Prevent Future  Deaths  dated  28  May  2024
issued by Assistant Coroner for South Wales Central  Ms Kerne Burge, following the Inquest touching
upon  the death of  Mrs Clara  Novella Winter who died at  Prince Charles Hospital on 19th November
2022.

An inquest held on 17 May 2024 concluded that, following routine and uneventful surgery to remove
her gall bladder, Mrs. Winter’s bowel became inflamed and resulted in complications with her existing
hernia, including further  adhesions, incarceration of  the  bowel, ischaemia and  a  bowel  perforation.
Emergency surgery was carried out to repair this but sadly Mrs. Winter was unable to recover.

The  matters  of  concern  that  were  identified  during  the  inquest  into  Ms  Winter’s  death  were  that,
following an internal review:

1. 

The Health Board accepted that significant learning was required by staff regarding
timeliness of escalation and maintenance of fluid balance charts and recommended
that  all  registered  nurses  from  surgical  wards  should  attend  an  ‘Acutely  Unwell*
study day, before the end of 2023.

Cadeirydd/Chair

Prlf Weithredwr/ Chief Executive;

Croeso i chi gyfathrebu a'r  bwrdd  iechyd yn  y Gymraeg neu'r  Saesneg. Byddwn  yn ymateb yn  yr un iaith a ni fydd hyn  yn  arwain at oedi,
You are welcome to correspond with the Health Board in Welsh or English.  IVe will respond accordingly and this will not delay  the  response

s : /. Cl.mu h b . n t i s , w a l e s

 2. 

This 'significant learning* has not been fully rolled out due to resourcing issues. No
completion date could be provided to me because the training is not considered to
be compulsory.

The Acutely Unwell Patient study day is facilitated by the outreach teams within Cwm Taf Morgannwg
UHB.  The  course  runs  monthly  within  Prince  Charles,  Royal  Glamorgan  and  Princess  of  Wales
hospitals.  Registered  nurses  are  booked  on  by  the  ward  manager. It  is  a  one-off, non-mandatory
course but it is advisable that staff complete at least every 3 years.

The  Acutely  Unwell  Patient  programme  includes  sessions  on  the  National  Early  Warning  Score
(NEWS), Situation, Background, Assessment and Recommendation (SBAR) communication to Acute
Kidney injury and Fluid Balance, Learning disability and reasonable adjustments in acute illness, A-E
assessment and sepsis.

From September 2024 the Acutely Unwell Course will be a CTM UHB standardised course available
on ESR  (Electronic Staff Record) for staff to book  and have  a larger capacity of training numbers of
25-30 spaces per month.  The course is promoted via posters and staff email and all ward managers
and senior nurses are encouraged to book staff members onto the course.

For  the  surgical wards within PCH  these are  the current numbers trained and  booked to  attend the
course:

PCH Surgical wards
Acutely Unwell Patient Training Day

PCH
Surgical
Ward
5
6

7
8

No of
Registered
Nurses
21
22
16

20

Staff trained

Compliance

Staff to be trained

19
17

4

15

90%
77%

*26%
75%

2 booked 2024
5 booked 2024
12 booked 2024

5 booked 2024

*2 courses cancelled due to doctor’s strikes in January and March 2024 impacting on compliance

Acutely Unwell Course dates for 2024

24th July
27th August
3rd September
11,h October
12th November
2nd December

As can be seen from the figures above, all staff have either completed the course or will have
attended the Acutely Unwell Patient study day within the surgical wards in PCH.

From August 2024 Outreach staffing will be at full establishment of 7wte within PCH (Prince Charles
Hospital), RGH (Royal Glamorgan Hospital), POW (Princess of Wales) hospital sites.

In  addition to the  Acutely Unwell Study Day,  the  outreach team  deliver training on the  deteriorating
patient  via  induction  for  graduate  nurses  biannually  and  by  student  nurse  learning  sessions.  The
teams also provide ad hoc bedside teaching as well as bitesize sessions.

Further training on the deteriorating patient is provided via the ALERT (Acute Life-Threatening Events
Recognition  and  Treatment)  course.  The  course  is  facilitated  by  the  senior  nurse  for  Acute
Deterioration and  Outreach services and  supported by  the  resuscitation service, outreach and  ANP
Advanced Nurse Practitioners.

 The  Health  Board  take  all  matters  of  concern  seriously  and  actively  addresses  issues  to  prevent
reoccurrence  in  future.  In  this  instance,  the  full  complement  of  outreach  staff  will  ensure  that  the
training is  run  monthly and  that all  staff  who  need  to complete the  training from  surgical wards  will
have done so by the end of 2024.

Yours sincerely,

Prif Weithredwr/Chief Executive