Rhian Roberts
14 Jul 2021 · Coroner John Gittins · North Wales (East and Central)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of toxicology screen execution
“On arrival at ICU the clerking-in doctor requested a toxicology screen to include paracetamol and salicylate levels (notwithstanding that blood tests to include this were already in hand) and there was no evidence available at the inquest to establish whether or not the toxicology screen requested by the doctor was undertaken and if not why not.”
2. draft SOP for life‑threatening blood result communication not approved
“An internal investigation by the health board following Mrs [name redacted]' death rightly established that action needed to be taken to update or modify the SOP for communicating of life-threatening blood results directly with clinical areas and an action plan indicated that this would be completed by the 30th of June 2021. At the time of the inquest on the 13th of July, the proposed update remained in draft form only and had not yet been approved.”
3. delays in investigating adverse incidents and implementing actions
“I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety.”
Later report
“I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner.”
Responses
2021-0242-Betsi-Cadwaladr-University-Health-Board_Published.pdf ↗· Betsi Cadwaladr University Health Board
Stated action
“On arrival at ICU the clerking-in doctor requested a toxicology screen to include paracetamol and salicylate levels (notwithstanding that blood tests to include this were already in hand) and there was no evidence available at the inquest to establish whether or not the toxicology screen requested by the doctor was undertaken and if not why not.”
Stated action · 20 July 2021
“An internal investigation by the health board following Mrs [name redacted]' death rightly established that action needed to be taken to update or modify the SOP for communicating of life-threatening blood results directly with clinical areas and an action plan indicated that this would be completed by the 30th of June 2021.”
Stated action · April 2021
“A new process to support the services to deliver timely investigations was commenced in April 2021.”