Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0701, written 28 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Oct 2024 |
|---|---|
| Reference | 2024-0701 |
| Deceased | Margaret Daly |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Wales prevention of future deaths reports (2019 onwards) · Hospital Death (Clinical Procedures and medical management) related deaths |
| 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 14th of June 2024 I commenced an investigation into the death of Margaret Joy Daly (DOB 23.10.32 DOD 10.6.24). The investigation concluded at the end of the inquest on the 24th of October 2024. The cause of death was recorded as being due to 1(a) Traumatic subdural haematoma (b) A fall 2. Delirium and the conclusion of the inquest was that the death was due to an accident. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are that Mrs Daly had been an in-patient at Wrexham Maelor Hospital and as a result of her being assessed as being at significant risk of falling she was on an enhanced level of observation. On the evening of the 1st of June 2024, Mrs Daly was exhibiting signs of anxiety and agitation and a member of nursing staff asked a doctor to review her. As the doctor was too busy to attend the ward, the nurse took Mrs Daly’s prescription chart to the doctor on another ward and he prescribed a sedative, namely lorazepam which was administered to her at 22.40 that evening with a further dose being given at 04.30 the following day. Later that morning Mrs Daly had an unwitnessed fall and sustained the injury which resulted in her death. The evidence supports a view that it is probable that she fell as a result of the effects of the sedation. 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. – The clinician who prescribed a sedative, did so, without reference to any of Mrs Daly’s notes other than her prescription chart and as a result was unaware of her enhanced falls risk or any other behavioural issues. Whilst I recognise that medication changes may be necessary without the doctor being able to review a patient in person, I am concerned that this may occur without the doctor having access to and considering her full medical records and risk assessments. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | 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 23rd of December 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 28th October 2024 Signature Senior 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: 20 December 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 Margaret Joy Daly I write in response to the Regulation 28 Report to Prevent Future Deaths dated 28 October 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching upon the death of Mrs Margaret Daly. I would like to begin by offering my deepest condolences to the family and friends of Mrs Daly. In the notice, you highlighted your concerns that the clinician who prescribed a sedative did so without reference to any of Mrs Daly’s notes other than her prescription chart, and that as a result they were unaware of her enhanced falls risk or any other behavioural issues. In response to the notice, I requested our East team Medical Director, Nursing Director and Pharmacy Director to consider your concerns and provide details of their plans to make our services as safe as possible, taking into account the learning from the inquest. Having considered the learning, a new process is being established by the East Medical Director to improve safety whilst recognising medication changes may be necessary without the doctor being able to review a patient in person. Doctors will be told to only prescribe without reviewing the patient in person if they have the notes brought to them, and nursing staff will be told they must relay the falls risk to the doctor at the time of discussing or escalating the patient. If the doctor has any doubts about safe prescribing then they will be told to attend the patient at their earliest opportunity and assess, or they should escalate to another doctor if they can’t get there quickly. The learning and actions from our East team will also be shared with our teams in central and west for wider learning. 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 longer term, and more sustainable solution is the development of an integrated electronic health record and I know our Chief Executive has discussed these developments with you. In summary, the Health Board is progressing plans and business cases regarding an integrated electronic health record system. The Health Board has now received formal confirmation from Welsh Government of the support for a Mental Health Electronic Health Record System, marking a significant step forward in relation to improving patient safety and experience, and the staff experience of coordinating and providing care. The Health Board will work closely with Cwm Taf Morgannwg University Health Board on this development as early implementers. The wider Electronic Health Record Programme, which will go beyond mental health, is now established. The Strategic Outline Case was approved by the Board earlier this year and submitted to Welsh Government officials. One meeting has been held and a subsequent meeting is being arranged. Whilst these solutions are longer term, they represent a significant endeavour with the Health Board taking a key and leading role in working with other organisations across Wales in developing the approach to such a major development. The Health Board is also working to roll out an Electronic Prescribing and Medication Administration System (ePMA). ePMA will replace the current paper based prescribing system across most specialties in acute and community services. Doctors, nurses, pharmacists and anyone who prescribes or works with medication will be trained to use the new system, which will run on laptops and tablets located in wards and other key areas. ePMA will streamline the process and make sure staff have access to a range of key information they need in one place. This is the Health Board’s largest-ever transformation project and we are committed to making it a success. We have taken a user-centred approach with a dedicated multi- disciplinary team of nurses, pharmacists, doctors, and IT professionals, plus Clinical Champions and expert trainers to ensure ePMA works effectively. We aim for the pilot sites to go-live in March 2025. I hope this letter sets out for you the actions that we are taking to address the concerns you raised. I would be happy to meet with you and discuss our work to improve patient safety 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 Daly for their loss. Yours sincerely Cyfarwyddwr Gweithredol Nyrsio a Bydwreigiaeth Executive Director of Nursing and Midwifery cc , Deputy Director for Legal Services
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