Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0387, written 22 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jul 2024 |
|---|---|
| Reference | 2024-0387 |
| Deceased | Philips Evans |
| Coroner | Kate Roberston |
| Coroner area | North Wales (East & Central) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Alcohol, drug and medication 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 1 August 2023 an investigation was commenced into the death of Philip Martin Evans (DOB 9/12/1984) who died on 26 July 2023. The investigation concluded at the end of the inquest on 18 July 2024. The conclusion of the inquest was by way of a narrative :- Philip Martin Evans had consumed a large quantity of medication at home and at the time of this consumption the state of his mind was impaired such that it cannot be said that he intended to end his life by this consumption at this time. At hospital, there were missed opportunities to provide treatment which would probably have afforded time to consider and initiate additional treatment options to the extent that death would probably then have not occurred when it did. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are as follows :- Philip Martin Evans was aged 38 at the time of his death on 26 July 2023. He had taken approximately 200 different tablets at his home address at around 9-9.30am on 26 July 2023. He was conveyed to Ysbyty Glan Clwyd by a police officer who had attended at his home following a concern for his safety. He was observed and went into cardiac arrest at 15:07. He was transferred to the intensive care unit and died a short time later. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | 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 Health Board conducted an investigation into Philip’s death to include a review of his previous mental health care and treatment as well as Emergency Department (ED) care and treatment. This did not identify any concerns from an ED perspective (conducted by a Head of Nursing). The report had been reviewed and approved by the Director or Nursing for the Mental Health and Learning Division and the Integrated Health Council Director. A request for a Statement as part of my investigation from an ED perspective prompted a second review of the ED care and treatment which was completed only on 10 July 2024. This was undertaken by an Emergency Department matron, approved by the Divisional Director, reviewed at an Incident Learning Panel and had Executive Approval which was completed on 10 July 2024, 8 days prior to the already listed Inquest. This identified omissions in the care and treatment. At the Inquest an ED Consultant gave evidence to the Investigation Report with this evidence differing in parts to the second investigation report. I am concerned that the quality, effectiveness and timeliness of the Health Board’s investigations means that issues or concerns with care and treatment are not being identified either at all or quickly enough in order to put in place additional measures or learning to prevent deaths in similar circumstances. I have issued several Reports pertaining to this very point over a long period and yet the same concerns remain. 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 16 September 2024. I, Kate Robertson, the Coroner, may extend the period. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | 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. A copy will also be sent to the Health Minister, . 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 22 July 2023 Signature Assistant Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
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: : Gofynnwch am / Ask for: E-bost / Email: Dyddiad / Date: 09 September 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 Philip Martin Evans I write in response to the Regulation 28 Report to Prevent Future Deaths dated 18 July 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching upon the death of Mr Philip Evans. I would like to begin by offering my deepest condolences to the family and friends of Mr Evans. In the notice, you highlighted your concerns over the quality, effectiveness and timeliness of the Health Board’s investigations, leading to issues or concerns with care and treatment not being identified, or identified quickly enough, in order to put in place learning and improvements. You also highlighted you had raised these concerns over a long period of time. As you know, the Health Board had started actions to implement a new incident procedure from April 2024. However, in response to the increasing number of concerns you raised and our own internal concerns, the new Chief Executive commissioned a significant programme of work to review previous investigations in order to gain a deep understanding of the issues. The Learning from Investigations Programme reviewed 262 investigations against a set of good practice standards that we developed. This work commenced in January 2024 and concluded at the end of June 2024 with a dedicated review team established and an oversight panel of senior leaders reporting to an executive steering group. The findings from this programme led to a clear understanding of where the problems were occurring in our processes. The Chief Executive therefore commissioned a further programme of work to develop this new Integrated Policy covering Incidents, Complaints and Mortality Reviews. This is known as the Integrated Concerns Policy. As Executive Director of Nursing and Midwifery, I oversaw this work along with the Acting Executive Director of Therapies and Health Sciences. The new policy was approved at 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 the Board meeting in July 2024, and become operational from 01 September 2024. My Deputy Directors of Nursing are leading implementation of this new policy through a working group consisting of our Patient Safety Team, Patient and Carer Experience Team, Complaints Team, Clinical Effectiveness Team and Legal Team. As with any major new policy, we expect full implementation to occur over the next three months. There are a number of changes being made through this policy as follows: • The new policy has five guiding principles as to how we approach incidents, complaints and mortality reviews, which are that our approach will be: 1) Person- centred, 2) Fair, 3) Open and Honest (candour), 4) Timely, effective and proportionate, and 5) Outcome and improvement focused. • An Integrated Concerns Hub will meet daily to ensure incidents, complaints and medical examiner referrals are triaged and triangulated to ensure the right review or investigation commences (proportionate to the issue) – our approach will be to investigate once, investigate well. • The Duty of Candour has been embedded into the process so it is seen as an integrated part of, and not separate to, the management of an incident or complaint. • As part of the new policy, there is new guidance, training and templates to be used and a new portal has been created on our staff intranet to access this in one place. • Clear deadlines are being set for each review and investigation – a new Investigations Tracker has been developed to monitor progress, which itself is part of our new Quality Dashboard providing ward to Board quality data. • Clear standards on what is expected in terms of investigation quality and engagement with those affected and those involved. • A weekly executive meeting will have oversight of commissioned investigations and rapid reviews. • A clearer and consistent approvals process is now established. • There are clear accountabilities now set on divisions to deliver the improvement and action plans. • The Patient Safety Team, Complaints Team and Clinical Effectiveness Team will conduct rolling audits of the Datix system to ensure divisions are uploading their Learning and Improvement Plans to Datix, that actions are being managed within date, and that evidence is being uploaded to support closure. This information will be used as part of governance and accountability processes and meetings to ensure the Health Board is delivering on its improvement commitments. Later this year, we will also be launching a new Digital Learning Portal which is being designed to capture and cascade learning. Once this is launched, divisions will be responsible for ensuring information is entered into this system to enable learning to be recorded and cascaded across the organisation. This development is the first of a kind in Wales and is currently being actively developed by our IT department. I want to assure you that the Health Board has understood and shared your concerns regarding our approach to investigations – and this new Integrated Concerns Policy is in response to those concerns and provides a clear framework for us to change how we work. I understand you have already been provided a copy of the new policy however I would be happy to meet with you and discuss the policy or our work to improve patient safety in more detail, or provide further information and assurance should that be helpful. I hope this letter sets out for you the actions that we are taking to address the concerns you raised. Once again, I offer my deepest condolences to the family and friends of Mr Evans for their loss. Yours sincerely Cyfarwyddwr Gweithredol Nyrsio a Bydwreigiaeth Executive Director of Nursing and Midwifery cc , Deputy Director of Quality
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