University Health Board
Action Taken
The Health Board has developed a corrective action plan and implemented actions including a registered nurse reflection, a standard operating procedure for oral opioid medication use, and RRAILS discussions and audits. (AI summary)
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Dear Mr Hughes RE: Regulation 28 Janice Davies Thank you for the correspondence in relation to the above Regulation 28 received on 28th December 2018, which details the areas of concern following the conclusion of the inquest held 14th December 2018. Please be assured that the Health Board has taken this matter extremely seriously, has learnt lessons following the investigation and the matters raised at the inquest into the circumstances of Mrs Davies' death: Comprehensive and robust action has been taken to minimise the risk of any recurrence_
1. Action taken to plan and monitor improvements A corrective Action Plan for Improvement has been developed which reflect the concerns identified within the Regulation 28 Report:
2. Actions Implemented A number of actions have been taken forward by the Health Board, the progress with these actions is reflected in the attached action plan which include:
1) The Registered nurse to personally reflect on the care given and the importance of undertaking observations and pain assessment following the administration of opioid medication.
2) A Standard Operating Procedure has been implemented to advise on the appropriate use of oral opioid medication in acute pain. A copy is attached.
3) This case has been discussed in the Rapid Response to Acute Illness (RRAILS) on 25th January 2019 and will be reviewed in the next RRAILS on 29th April 2019. The departmental manager to ensure score audits are undertaken. Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF4S 4SN Chair Cadeirydd; Professor Marcus Longley Chief Executive Prif Weithredydd: Mrs A Williams Cwm Tal University Health Board the operational name 0f the Cwm Taf University Health Board Bwrda lechyd Prifysgol Cwm Tal yw enw gwerhredol Bwrdd lechyd Prifysgol Cwm Tal pain
I sincerely hope that this information and enclosed Action Plan will reassure you that the Health Board has learnt important lessons from the investigation into the care provided to Mrs Davies and that effective action has now been taken to prevent further deaths; Iwould like to convey once again my deepest sympathy and sincere apologies to Mrs Davies' family for the failings identified.
1. Action taken to plan and monitor improvements A corrective Action Plan for Improvement has been developed which reflect the concerns identified within the Regulation 28 Report:
2. Actions Implemented A number of actions have been taken forward by the Health Board, the progress with these actions is reflected in the attached action plan which include:
1) The Registered nurse to personally reflect on the care given and the importance of undertaking observations and pain assessment following the administration of opioid medication.
2) A Standard Operating Procedure has been implemented to advise on the appropriate use of oral opioid medication in acute pain. A copy is attached.
3) This case has been discussed in the Rapid Response to Acute Illness (RRAILS) on 25th January 2019 and will be reviewed in the next RRAILS on 29th April 2019. The departmental manager to ensure score audits are undertaken. Return Address: Cwm Taf University Health Board, Headquarters, Navigation Park, Abercynon, CF4S 4SN Chair Cadeirydd; Professor Marcus Longley Chief Executive Prif Weithredydd: Mrs A Williams Cwm Tal University Health Board the operational name 0f the Cwm Taf University Health Board Bwrda lechyd Prifysgol Cwm Tal yw enw gwerhredol Bwrdd lechyd Prifysgol Cwm Tal pain
I sincerely hope that this information and enclosed Action Plan will reassure you that the Health Board has learnt important lessons from the investigation into the care provided to Mrs Davies and that effective action has now been taken to prevent further deaths; Iwould like to convey once again my deepest sympathy and sincere apologies to Mrs Davies' family for the failings identified.