Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0323, written 14 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 14 Jun 2024 |
|---|---|
| Reference | 2024-0323 |
| Deceased | Eric Thompson |
| Coroner | Kate Robertson |
| 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.
Kate Robertson Assistant 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) 1 CORONER I am Kate Robertson, Assistant 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 11 January 2023 an investigation was commenced into the death of Eric Thompson (DOB 13/4/1941) who died on 28 December 2022. The investigation concluded at the end of the inquest on 14 June 2024. The narrative conclusion of the Inquest was as follows:- Eric Thompson died on 28 December 2022 at Ysbyty Glan Clwyd where there were missed opportunities to provide timely care and treatment to prevent the condition, hyperkalaemia, which contributed to his death at this time. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows :- Eric Thompson presented at Ysbyty Glan Clwyd on 27 December 2022 at 13:58 with confusion and poor mobility on the background of treatment for a urinary tract infection. He had bloods taken at 17:28. An attempt was made by the laboratory to telephone the emergency department with the abnormal results (high potassium). There was no answer. A second attempt was made at 18:35 and the results were relayed to the department. These were not initially documented or escalated but had been included on the system. Eric Thompson remained in the department. At 21:35 a clinician noted a high NEWS score (7) and became aware of the abnormal blood results. Eric Thompson did not receive treatment for the hyperkalaemia. He went into cardiac arrest at 02:50 and died shortly thereafter. He died from cardiac related issues contributed to by hyperkalaemia and diabetes mellitus. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN 5 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 – The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call. They were not actioned, nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson. There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary. 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 9 August 2024. I, Kate Robertson, 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 14 June 2024 Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Signature Assistant 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 Kate Robertson HM Assistant Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Ein cyf / Our ref: Eichcyf / Your ref: Dyddiad / Date: 31st July 2024 Dear Ms Robertson, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Eric Thompson I write in response to the Regulation 28 Report to Prevent Future Deaths dated 14 June 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching upon the death of Mr Eric Thompson. I would like to begin by offering my deepest condolences to the family and friends of Mr Thompson, and to apologise on behalf of the Health Board for the concerns that you identified in Mr Thompson’s care and treatment. In the notice, you highlighted your concerns that there is no electronic method or system by which the laboratory can send results to the emergency department quickly and efficiently, with an alert to indicate abnormal results. In response, our three hospital Medical Directors have reviewed the concerns you identified alongside colleagues in our Digital, Data and Technology Department. Our Deputy Executive Medical Director, who is a Consultant Emergency Medicine Physician, has also provided expert input into the discussions. Our existing digital system, the Welsh Clinical Portal (WCP), which is used across various services, does notify a user that results are back for a particular patient once they log into the system, but it does not provide any further detail until the user goes into the individual patient details. As you will know from our responses to other notices, the Health Board is committed to improved and integrated digital records and we will continue to work with national partners across Wales whom we rely upon to deliver this. The Health Board continues to do all it can on the issue of digital records, and the Board approved an outline business case for an All Age Mental Health Digital Solution at its meeting on 25 July 2024. This case will now be reviewed at the Welsh Government investment panel prior to a recommendation being made to the Cabinet Secretary for Health and Social Care. Whilst this of course would not be relevant in Mr Thompson’s case, I hope it shows to you the extensive work we are doing to seek the significant funding needed to move towards improved digital records. In specific relation to the issue of abnormal results being communicated to the emergency department (ED) quickly, our Medical Directors have discussed this with senior clinicians and they have identified the telephone alert process is standard in most EDs. This method of alert is more likely to bring the abnormal result to the attention of the department than an IT related alert, due to the dynamic nature of the ED and the fact that most clinicians will be working agile and with patients rather than by a computer. Therefore, the arrangement of phone alerts would still have a valuable role in safety and is not likely to be replaced by any future electronic system (although we acknowledge such systems may provide improved access to information). We do however fully recognise that on this occasion the process failed. You, and the family and friends of Mr Thompson, will therefore rightly want assurance that we will learn and improve our processes in order to do all we can to prevent a recurrence. To that end, our three hospital Medical Directors will work with all of our three ED teams to review, revise and update the processes in place to ensure there is a clear mechanism for telephone alerts to be received and acted upon. That work will include ensuring the learning from this case is cascaded, that procedures are considered and updated, and importantly that staff are aware of those procedures. We will seek evidence from each of the three hospitals that this work has been undertaken – and we expect that work to be undertaken and evidence provided by the end of September 2024 at the very latest (which recognises the summer pressures that our services face). I hope this letter sets out for you the actions that we are taking to address the concerns you raised. 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 Mr Thompson for their loss. Yours sincerely Cyfarwyddwr Gweithredol Nyrsio a Bydwreigiaeth / Executive Director of Nursing and Midwifery cc
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