Maria Shafighian
21 Apr 2023 · Coroner Caroline Saunders · Gwent
The coroner's concerns
1. delayed communication of critical clinical information
“the process by which the SALT team notified the ENT department of the change in [the deceased]'s presentation and the development of dysphagia was through an internal postal system”
2. lack of urgent notification system
“No evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team and there was no process for ensuring that the post was dealt with in a timely manner”
3. month long delay in notification
“there appears to have been a delay of a month between the letter being sent and being noticed by the ENT team”
Responses
2023-0205-Response-from-Aneurin-Bevan-University-Health-Board.pdf ↗· Aneurin Bevan University Health Board
Stated action
“internal referrals to the ENT department need to be sent straight to the Central Registration department for them to take action and upload the information on the referral, and send this electronically to the ENT consultants for triage”