Trevor Reynolds
6 May 2022 · Coroner John Gittins · North Wales (East and Central)
The coroner's concerns
1. delayed implementation of new Standard Operating Procedure
“the health board did not fully implement a new Standard Operating Procedure, which was introduced to address this issue, until December 2021, seven months after the death of Mr [name redacted]”
2. lack of acknowledgement of new SOP by secretaries
“acknowledgement of the existence of the new SOP by Oncology and Haematology Secretaries was not completed until the 22nd of February 2022”
3. incomplete audit of SOP compliance
“at the time of the inquest, eleven days prior to the anniversary of Mr [name redacted]' death the health board had not completed an audit process to ensure that the changes which had been introduced were being complied with and were therefore effective”
4. slow adoption of safe working practices
“the length of time which it takes to implement changes and to ensure that new safe working practices are introduced and adopted by staff, results in the health board allowing known risks to patients to continue and therefore presents a risk to life”