Source · Prevention of Future Deaths

Eifion Huws

Ref: 2023-0185 Date: 8 Jun 2023 Coroner: Kate Sutherland Area: North West Wales Responses identified: 1 / 1 View PDF

Inadequate access to comprehensive patient records (due to electronic vs. hard copy discrepancies) hindered emergency staff decision-making. The Health Board's investigation also failed to address this critical information-sharing flaw or improve overall investigation timeliness.

Date 8 Jun 2023

56-day deadline 3 Aug 2023 est.

Responses identified 1 of 1

Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

1. a. During the Inquest evidence was heard that Eifion’s GP had made a ‘very urgent’ referral to the Single Point of Access and Allocation (SPOAA) on 13 May 2022 indicating that on the background of attempts at ending his life, he was extremely concerned that Eifion was experiencing deterioration in his mental state. This document was contained within the hard copy set of notes held by the Psychiatric Liaison Team. When Eifion attended at the Emergency Department the following day, on 14 May 2022, the Emergency department staff were not aware of this ‘very urgent’ referral as they only had access to the electronic notes and not the hard copy notes. Had they been aware it is likely to have further informed their decision making. It is concerning that the process of ensuring electronic notes to allow for fully informed decisions around treatment and care based on all available records, is not available to staff. It was not clear at Inquest whether the transition from paper-based notes to electronic notes was a Health Board initiative or a nationally followed initiative. Either way, any delay in ensuring all notes are available electronically is potentially harmful to patients.
b. During the evidence it was accepted that ‘a’ above was not a consideration for improvement as part of the Health Board’s investigation and so was not an action within the Action Plan upon which it could make improvements or plan to make improvements. It is surprising that the Health Board did not consider this as an issue which required further consideration and improvements in its learning and improvement.
2. An investigation was commenced by the Health Board into Eifion’s death which appears to have been concluded in July 2022 but did not appear to be finalised and ready for sharing / disseminating until March 2023. I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations, specifically in relation to investigations from deaths in 2020 and 2021. Whilst I have previously been advised of improvements into investigation processes in respect of more recent deaths the issue of timeliness remains. Eifion died in 2022 and yet the time it took for the investigation to be completed and shared, with actions undertaken has been too long. I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner. |

ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

Responses

1 respondent

Betsi Cadwaladr University Health Board NHS / Health Body

8 Jun 2023 PDF

Action Taken

The Health Board is implementing the Welsh Community Care Information System (WCCIS) for integrated health and social care records and has reviewed its incident process, implemented rapid learning panels, and prioritized completion of overdue investigations and action plans. (AI summary)

View full response

Dear Ms Robertson,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Eifion Wyn Huws

I write in response to the Regulation 28 Report to Prevent Future Deaths dated 08 June 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Mr Eifion Wyn Huws.

I would like to begin by offering my deepest condolences to the family and friends of Mr Huws for their loss.

In the Notice, you raised a number of concerns.

In response to the inquest and the Notice, I requested our Mental Health and Learning Disability Division (MHLD) to carefully consider your concerns and provide details of their plans to make our services as safe as possible. The findings of those considerations and our actions are detailed below.

The Welsh Government have advocated the use of an information technology (IT) system that links health and social care through the use of an integrated care platform. The Welsh Community Care Information System (WCCIS) will enable a single integrated health and social care record. This system will help social services (adults & children) and a range of community health services (including mental health, therapies and community nursing) to ensure that care and support for individuals, families and communities are more effectively planned, co-ordinated and delivered. It will support information sharing requirements, case management and workflow for health and social care organisations across Wales. It will show where a patient is within their treatment journey and alert health professionals to key data, which will support the delivery of effective treatment. WCCIS will interface with a range of other appropriate systems across local authorities and NHS organisations wherever a patient is treated, in their own home, in the community or in a hospital. Our MHLD Division engagement in the WCCIS Project is ongoing, however its implementation has faced national delays. The Health Board WCCIS Project Team engaged with MHLD services to review system functionality and identified that further

Dyddiad / Date: 31 July 2023 Kate Robertson Senior Coroner for North West Wales HM Coroner’s Office Shirehall Street Caernarfon Gwynedd LL55 1SH

Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG

national development work was required to meet our requirements. This work has been ongoing in parallel and conjunction with all Health Boards in Wales. The Health Board’s implementation of WCCIS is monitored organisationally through the WCCIS Project Board. With regard to the investigation report and action plan into the care and treatment delivered to Mr Huws, the benefits of an integrated IT system should have been considered with reference to the implementation of WCCIS within the action plan and this has been discussed with the investigating officer. I would like to sincerely apologise for the delays in the completion and timeliness of the investigation report and the implementation of the subsequent action plan. I have acknowledged before, in a previous letter to you, the unacceptable impact on patients, families and the coronial process from delays in investigations and actions plans and I remain firm in my commitment to improve our responsiveness.

In my previous letter to you on 09 May 2023, I was able to inform you of the changes that have taken place within the Health Board; these included a review of the incident process, and the quality control process delivered by the quality governance teams. The Health Board have also implemented rapid learning panels and incident learning panels. The MHLD Division have prioritised the completion of overdue investigations and action plans and there has been a significant reduction in the number overdue. The Division continues to meet weekly to address any remaining overdue investigation reports and to ensure that actions are monitored for completion. I recognise the importance of ensuring this improvement is maintained and I am assured that we have the mechanisms in place to monitor this and to take further action as required.

I hope this letter sets out for you the actions taken to ensure the concerns raised by yourself and Mr Huws’ family are being addressed.

Once again, I would like to offer my deepest condolences to the family and friends of Mr Huws for their loss.

Report sections

Investigation and inquest

On 21 June 2022 an investigation was commenced into the death of Eifion Wyn Huws (DOB 25/4/59) who died on 10 June 2022. The investigation concluded at the end of the inquest on 7 June 2023. The conclusion of the inquest was suicide.

Circumstances of the death

The circumstances of the death are as follows : Eifion Wyn Huws was aged 63 at the time of his death on 10 June 2022. He had a past medical history of non-Hodgkin’s lymphoma having had the diagnosis on 12 January 2022 and poorer mental health as a result. Other than the lymphoma he had no other significant past medical history. The anticipation of awaiting scans and treatment impacted severely upon his mental health but he had significant family support. Eifion was regularly reviewed by a GP and medicated accordingly. He had previous attempts at self-harm by way of medication overdose or self-inflicted injury. He had been under the care of the Community Mental Health Team including Home Treatment Team and primary care since early 2022 up to his death. His acts of self-harm were impulsive but serious. On 10 June 2022 Eifion had left his home address to attend his daughter’s home across the road to let the cat out. There was a concern for Eifion when he did not reply to a text message from his wife around 15 mins later who then attended at their daughter’s home and on opening the front door found Eifion suspended by a ligature . Eifion was confirmed as having passed away at the property on 10 June 2022 at 10.37 by an attending paramedic.

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Report details

Reference: 2023-0185
Date of report: 8 June 2023
Coroner: Kate Sutherland
Coroner area: North West Wales

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Aug 2023 (estimated).

Sent to

Betsi Cadwaladr University Health Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.