Cwm Taf Morgannwg University Health Board
NHS / Health Body
Action Taken
Cwm Taf Morgannwg UHB has provided training to staff on surgical wards in PCH to recognise and manage acutely unwell patients, with nearly all staff trained or booked for training by the end of 2024. Outreach staffing will be at full establishment from August 2024 and will deliver training on the deteriorating patient. (AI summary)
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Dear Ms Burge, I am writing in response to a Regulation 28: Report to Prevent Future Deaths dated 28 May 2024 issued by Assistant Coroner for South Wales Central Ms Kerne Burge, following the Inquest touching upon the death of Mrs Clara Novella Winter who died at Prince Charles Hospital on 19th November
2022. An inquest held on 17 May 2024 concluded that, following routine and uneventful surgery to remove her gall bladder, Mrs. Winter’s bowel became inflamed and resulted in complications with her existing hernia, including further adhesions, incarceration of the bowel, ischaemia and a bowel perforation. Emergency surgery was carried out to repair this but sadly Mrs. Winter was unable to recover. The matters of concern that were identified during the inquest into Ms Winter’s death were that, following an internal review:
1. The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts and recommended that all registered nurses from surgical wards should attend an ‘Acutely Unwell* study day, before the end of 2023. Prlf Weithredwr/ Chief Executive; Cadeirydd/Chair Croeso i chi gyfathrebu a'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. IVe will respond accordingly and this will not delay the response s : /. Cl.mu hb .ntis,wales
2. This 'significant learning* has not been fully rolled out due to resourcing issues. No completion date could be provided to me because the training is not considered to be compulsory. The Acutely Unwell Patient study day is facilitated by the outreach teams within Cwm Taf Morgannwg UHB. The course runs monthly within Prince Charles, Royal Glamorgan and Princess of Wales hospitals. Registered nurses are booked on by the ward manager. It is a one-off, non-mandatory course but it is advisable that staff complete at least every 3 years. The Acutely Unwell Patient programme includes sessions on the National Early Warning Score (NEWS), Situation, Background, Assessment and Recommendation (SBAR) communication to Acute Kidney injury and Fluid Balance, Learning disability and reasonable adjustments in acute illness, A-E assessment and sepsis. From September 2024 the Acutely Unwell Course will be a CTM UHB standardised course available on ESR (Electronic Staff Record) for staff to book and have a larger capacity of training numbers of 25-30 spaces per month. The course is promoted via posters and staff email and all ward managers and senior nurses are encouraged to book staff members onto the course. For the surgical wards within PCH these are the current numbers trained and booked to attend the course: PCH Surgical wards Acutely Unwell Patient Training Day PCH No of Staff trained Compliance Staff to be trained Surgical Registered Ward Nurses 5 21 19 90% 2 booked 2024 6 22 17 77% 5 booked 2024 7 16 4
*26% 12 booked 2024 8 20 15 75% 5 booked 2024
*2 courses cancelled due to doctor’s strikes in January and March 2024 impacting on compliance Acutely Unwell Course dates for 2024 24th July 27th August 3rd September 11,h October 12th November 2nd December As can be seen from the figures above, all staff have either completed the course or will have attended the Acutely Unwell Patient study day within the surgical wards in PCH. From August 2024 Outreach staffing will be at full establishment of 7wte within PCH (Prince Charles Hospital), RGH (Royal Glamorgan Hospital), POW (Princess of Wales) hospital sites. In addition to the Acutely Unwell Study Day, the outreach team deliver training on the deteriorating patient via induction for graduate nurses biannually and by student nurse learning sessions. The teams also provide ad hoc bedside teaching as well as bitesize sessions. Further training on the deteriorating patient is provided via the ALERT (Acute Life-Threatening Events Recognition and Treatment) course. The course is facilitated by the senior nurse for Acute Deterioration and Outreach services and supported by the resuscitation service, outreach and ANP Advanced Nurse Practitioners.
The Health Board take all matters of concern seriously and actively addresses issues to prevent reoccurrence in future. In this instance, the full complement of outreach staff will ensure that the training is run monthly and that all staff who need to complete the training from surgical wards will have done so by the end of 2024.
2022. An inquest held on 17 May 2024 concluded that, following routine and uneventful surgery to remove her gall bladder, Mrs. Winter’s bowel became inflamed and resulted in complications with her existing hernia, including further adhesions, incarceration of the bowel, ischaemia and a bowel perforation. Emergency surgery was carried out to repair this but sadly Mrs. Winter was unable to recover. The matters of concern that were identified during the inquest into Ms Winter’s death were that, following an internal review:
1. The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts and recommended that all registered nurses from surgical wards should attend an ‘Acutely Unwell* study day, before the end of 2023. Prlf Weithredwr/ Chief Executive; Cadeirydd/Chair Croeso i chi gyfathrebu a'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. IVe will respond accordingly and this will not delay the response s : /. Cl.mu hb .ntis,wales
2. This 'significant learning* has not been fully rolled out due to resourcing issues. No completion date could be provided to me because the training is not considered to be compulsory. The Acutely Unwell Patient study day is facilitated by the outreach teams within Cwm Taf Morgannwg UHB. The course runs monthly within Prince Charles, Royal Glamorgan and Princess of Wales hospitals. Registered nurses are booked on by the ward manager. It is a one-off, non-mandatory course but it is advisable that staff complete at least every 3 years. The Acutely Unwell Patient programme includes sessions on the National Early Warning Score (NEWS), Situation, Background, Assessment and Recommendation (SBAR) communication to Acute Kidney injury and Fluid Balance, Learning disability and reasonable adjustments in acute illness, A-E assessment and sepsis. From September 2024 the Acutely Unwell Course will be a CTM UHB standardised course available on ESR (Electronic Staff Record) for staff to book and have a larger capacity of training numbers of 25-30 spaces per month. The course is promoted via posters and staff email and all ward managers and senior nurses are encouraged to book staff members onto the course. For the surgical wards within PCH these are the current numbers trained and booked to attend the course: PCH Surgical wards Acutely Unwell Patient Training Day PCH No of Staff trained Compliance Staff to be trained Surgical Registered Ward Nurses 5 21 19 90% 2 booked 2024 6 22 17 77% 5 booked 2024 7 16 4
*26% 12 booked 2024 8 20 15 75% 5 booked 2024
*2 courses cancelled due to doctor’s strikes in January and March 2024 impacting on compliance Acutely Unwell Course dates for 2024 24th July 27th August 3rd September 11,h October 12th November 2nd December As can be seen from the figures above, all staff have either completed the course or will have attended the Acutely Unwell Patient study day within the surgical wards in PCH. From August 2024 Outreach staffing will be at full establishment of 7wte within PCH (Prince Charles Hospital), RGH (Royal Glamorgan Hospital), POW (Princess of Wales) hospital sites. In addition to the Acutely Unwell Study Day, the outreach team deliver training on the deteriorating patient via induction for graduate nurses biannually and by student nurse learning sessions. The teams also provide ad hoc bedside teaching as well as bitesize sessions. Further training on the deteriorating patient is provided via the ALERT (Acute Life-Threatening Events Recognition and Treatment) course. The course is facilitated by the senior nurse for Acute Deterioration and Outreach services and supported by the resuscitation service, outreach and ANP Advanced Nurse Practitioners.
The Health Board take all matters of concern seriously and actively addresses issues to prevent reoccurrence in future. In this instance, the full complement of outreach staff will ensure that the training is run monthly and that all staff who need to complete the training from surgical wards will have done so by the end of 2024.