Annette Lewis

YSBRYOOU GWELLA

baad POBL GOFAL

BYFOCOL

Bwrdd lechyd Prifysgo

a 4
Cwm Taf Morgannwg & > : e yt Xe
Wy?

University Health Board

SUSTAINING IMS FIRING IMPROVING CREATING
OUR FUTURE PEOPLE CARE REALTH

Cyfeiriad Dychwelyd/ Return Address:
Bwrdd lechyd Prifysgol Cwm Taf Cwm Taf Morgannwg University

Morgannwg Health Board
Pencadlys Headquarters
Uned 3, TY Ynysmeurig Unit 3, Ynysmeurig House
Parc Navigation, Abercynon Navigation Park
CF45 4SN Abercynon
CF4S 4SN

Ffén/Tel: 01443 744800

Eich cyf/Your Ref:

Ein cyf/Our Ref:

Ebost Email:

Dyddiad/Date: uly 2025

PRIVATE & CONFIDENTIAL
Kerrie Burge

Assistant Coroner

The Old Court House
Court House Street
Pontypridd

CF37 JW

Dear Ms Burge,

| am writing in response to a Regulation 28 Report issued to Cwm Taf Morgannwg
University Health Board (CTM UHB) on the 6 March 2025 following the inquest
touching upon the death of Annette Lewis. The Health Board acknowledges the
matters of concerns raised in relation to the care that was provided at the Princess of
Wales Hospital specifically in relation to a failed discharge policy and action has been
taken to address this.

1. General Surgery Policy

CTM now has active and up to date guidelines to prevent recurrence of what happened
in Ms Lewis’ case. This is a General Surgery policy that applies to the General Surgeons
as well as to the Emergency Department (who have also had it discussed and shared

Cadeirydd /Chair: A Prif Weithredwr/Chief Executive:

Croeso i chi gyfathrebu &’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. We will respond accordingly and this will not delay the response.

httos://ctmuhb.nhs,wales

wiuely — please see below in Emergency Department section). The Guidelines for care
and treatment for patients who return to an Emergency Department (ED) within CTM
UHB with general surgical conditions following discharge from hospital within CTM
UHB were approved at Quality & Safety Committee on the 25" March 2025. These
guidelines are operational across the Health Board. It was discussed at the Surgical
Governance Meeting (pan-health Board) on 13% March 2025 department Morbidity
and Mortality meeting, and the new policy was shared with the entire team by email.
Those involved have reflected and evidenced this as part of their appraisal. Finally, this
policy has been included in our induction presentation to all new starters. It is available
on the Health Board SharePoint where all Guidelines and Policies are located for rapid
access by colleagues.

2. Emergency Department Policy

The Princess of Wales Emergency Department Guidelines have been circulated to all
Doctors and Clinical Teams. In addition, information (including laminates clearly
displayed on the department walls) is available in minors, paediatric triage and BRATZ
{majors triage / rapid assessment) for the whole multi-disciplinary team to see, be
aware of and act upon. This is also the case in key areas in the other CTM Emergency
Departments Royal Glamorgan and Prince Charles. There is a Princess of Wales
Emergency Department Handbook and this policy has been added to it. This Handbook
is available for all staff to refer to including agency and locum doctors.

We hope that these actions, development and awareness of these guidelines can
demonstrate a robust response to the extremely sad death of Mrs Annette Lewis and
that the organisation has learned. We are confident that these steps would prevent
further events of patient representing with symptoms.

Yours sincerely,

Medical Director

GIG Bwrdd lechyd Prifysgol

Cwm Taf Morgannwg
N HS University Health Board

Guidelines for care and treatment for patients who return to an Emergency
Department (ED) within CTM UHB with general surgical conditions following
discharge from hospital within CTM UHB.

Clinical Polic

Nor

||
Quality & Safety Committee
[March 2027, SC~—~SCSd

Final version 1.0

Target Audience:

Clinical Staff involved in the care of
managing patients attending
emergency departments across
CTMUHB

Cwm Taf Morgannwg University
Health Board Emergency

Department Clinical Lead and
General Surgical Clinical Directors
Nursing, Midwifery & Medical staff at
Cwm Taf Morgannwg University
Health Board. Via Sharepoint

Guidelines Definition

Clinical guidelines are systemically developed statements that assist
clinicians and patients in making decisions about appropriate treatments
for specific conditions.

They allow deviation from a prescribed pathway according to the
individual circumstances and where reasons can be clearly demonstrated
and documented.

Minor Amendments

If a minor change is required to the document, which does not require a
full review please identify the change below and update the version
number.

Type of Why change Date change | Version | Name of
is made responsible
erson
Contents
Guidelines DefiNition........ceeceeseccecacsceeuecscsssaueeeresenseneeneeeensues 2
Minor AMENAMENES 20... cc ccceesesececseeeceseneaeneeensepeeteetereceutereeeceteues 2
1.0 PUPPOSE oo... cece eeeeneceeceteeenenseaceesaeuteasneseesaeneas 3
2.0 Patients who return to an Emergency Department 3
3.0 Care of returning patients having undergone a surgical procedure or
recent admission under general SUrGePry..........cccccccsccscsssecectseeverseseees 3
4.0 Responsibility of investigation reSults oo... ccecesecscscseeersesees . 4

1.0 Purpose

The following guideline is to ensure appropriate care and treatment for
patients who return to an Emergency Department (ED) within CTM UHB
following either attendance to or discharge from hospital after a post-
surgical procedure within CTM UHB.

2.0 Patients discharged by ED and returning to the Emergency
Department

e RCEM Consultant sign off standards states that ‘any patient with an
unscheduled return to ED within 72 hours with the same condition
must be reviewed by an ED consultant prior to discharge by ED team’.

e When a consultant is not available on site, the RCEM guidance
supports review prior to discharge by a Tier 4 clinician (ST4+ or
equivalent sign off)

3.0 Patients returning to the Emergency Department who have
been under the care of the General Surgical team in CTMUHB

3.1 Return following discharge by General Surgical team

Patients that return to ED within 7 days after a surgical discharge (either
from ED/AESU/SDEC/SAU or the ward) with the same or worsening
problem can be discussed with surgical team for review after triage. These
patients do not need formal ED assessment unless the patient is triaged as
unstable.

Patients that return after 7 days to ED to be reviewed by ED team and
assessed.

Exception: Patients discharged with uncomplicated rib fractures

3.2 Returning patients from CTMUHB within one month of
undergoing a general surgical procedure:

All patients presenting to ED with potential issues related to a recent
general surgical procedure within CTMUHB can be referred back to the on
call general surgical team after triage (if stable). They do not require a
formal ED assessment unless the patient is triaged as unstable.

3.3. Returning patients from CTMUHB over one month post-
surgical procedure:

All patients presenting to ED with potential issues related to a general
surgical procedure within CTMUHB performed greater than one month
previously, will require an assessment by the ED team with onwards referral
as appropriate.

Exception: Patient with a known (chronic) on-going surgical
problems, such as a chronic wound or surgical drain. These patients
can be referred direct to the on call surgical team.

3.4 Patients attending ED having undergoing surgical procedures
from other specialties or from outside CTMUHB.

All patients presenting to ED with potential issues related to a post surgical
procedure from outside CTMUHB will require assessment by the ED team
with onwards referral as appropriate.

4 Responsibility of investigation results

The responsibility of checking and acting on any test result falls on the
clinician requesting the test.

As per the GMC, Good Medical Practice (65c), robust handover of any
outstanding test results is essential.

All doctors...must be confident that information necessary for ongoing care has been
shared:

i. before you go off duty
ii. before you delegate care, or
iii. before you refer the patient to another health or social care provider.

It is responsibility of the ED team to follow up any investigations requested
for discharged patients that are not referred on.

Once referred, the accepting team must follow up and manage any
investigations for patients requested up to and following review. This
includes any investigation requested by the team, even if the patient is
referred on to another specialty or discharged (inclusive of investigations
requested by ED prior to referral as these are handed over as part of the
initial referral process).

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