Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0103, written 21 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Feb 2025 |
|---|---|
| Reference | 2025-0103 |
| Deceased | Ann Cotgrove |
| 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 3rd of May 2022 I commenced an investigation into the death of Ann Margaret Cotgrove (DOB 10.08.51 DOD 03.05.22). The investigation concluded at the end of the inquest on the 20th of February 2025. The cause of death was recorded as being due to 1(a) Peritonitis , Acute Liver Failure and Bronchopneumonia 1b Gall Bladder Perforation 1c Endoscopic retrograde cholangiopancreatography due to obstructive jaundice and the conclusion of the inquest was that the death was due to medical misadventure. 4 CIRCUMSTANCES OF THE DEATH The circumstances of the death are that Miss Cotgrave had been admitted to Glan Clwyd Hospital on the 31st of March 2022 and was being investigated to establish the cause of her jaundice. She did not undergo a required ERCP until the 19th of April and on the 22nd of April was found to have sustained a perforation which is likely to have occurred in the course of that procedure. By that time she was too unwell to undergo reparative surgery and she passed away on the 3rd of May 2022. The delay in her undergoing the ERCP was due (inter alia) to the consultant gastroenterologist requesting that advice from tertiary centre in Liverpool be obtained prior to the procedure due to a suspicion of malignancy. He was subsequently informed that advice had been received indicating the ERCP should be undertaken at Glan Clwyd and he therefore proceeded. Whilst there is no reason to doubt the veracity of the consultant’s evidence, that advice from the tertiary centre had been sought, there is no documented evidence in relation this. 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. – That there was no record of any discussions which took place been Glan Clwyd and the tertiary centre and no formal documented process in relation to such referrals and the subsequent advice which was provided and thereafter acted upon. 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 18th April 2025 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 21st February 2025 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: I Eichcyf / Your ref: : 03000 840135 Gofynnwch am / Ask for: E-bost / Email: Dyddiad / Date: 16 April 2025 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 Ann Margaret Cotgrove I write in response to the Regulation 28 Report to Prevent Future Deaths dated 21 February 2025, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching upon the death of Mrs Cotgrove. I would like to begin by offering my deepest condolences to the family of Mrs Cotgrove. As you know, the Board is committed to building a learning and improving organisation and we take all Prevention of Future Death Notices very seriously. In the notice, you highlighted your concerns that whilst expert advice from a specialist tertiary hospital had been sought, there was no documented process or evidence in relation this The issues identified in your notice were shared with the clinical team involved in this case immediately after the inquest for reflection and learning. The learning contained in your notice has also been shared with our Reducing Avoidable Mortality Group at its meeting in April 2025. This group leads on our work across North Wales to learn from deaths and reduce avoidable mortality with representatives attending from all services. However, we felt that the absolute necessity for the documentation of discussions between clinicians, particularly when seeking opinion from a tertiary centre, is an important learning point to widely share. As such, we have developed a case summary presentation which our Central Health Community Medical Director will share across their services through clinical governance meetings. This will help ensure all services learn from this case. We will also be sharing the case summary with our other two acute hospital Medical Directors for wider cascade. 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 In addition, it is important we recognise the challenges our clinical staff have with our current record keeping arrangements, which includes some paper records and some electronic records (which can be disjointed). As you know, the Health Board is actively progressing an integrated digital solution and we believe this will significantly improve the quality of patient records – the Health Board is at the forefront of this work across Wales. We have developed an Outline Business Case and this is due for approval at our Board in June 2025, before submission to the Welsh Government in July 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 of Mrs Cotgrove 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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