Source · Prevention of Future Deaths

Raymond Edwards

Ref: 2017-0029 Date: 10 Feb 2017 Coroner: Nicola Jones Area: North Wales (Eastern and Central) Responses identified: 1 / 1 View PDF

A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.

Date 10 Feb 2017

56-day deadline 7 Apr 2017

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

_ The from Glan

(1) During the Inquest it became clear that there is no reliable system or protocol for the dissemination of histology results to the named consultant for a patient_ In this case the consultant for Mr Edwards informed the inquest that the histology result had gone to the file of Mr Edwards as he had been discharged. He did not chase the result as the operation passed without incident, The Consultant informed the court that had he had the result of histology showing amiloidosis that he would immediately have referred the patient on for urgent investigation of this serious condition. Having had these results at an early stage would have informed the treatment for Mr Edwards subsequently: The fact that this information was not passed in a timely fashion did not cause or contribute to the death of Mr Edwards_ However, it is clear that unless there is a clear system for bringing histology results to the attention of a named Consultant that there could be a death in future. The consultant himself identified a need for a more robust system of delivering_histology reports to consultants

Responses

1 respondent

University Health Board

10 Feb 2017 PDF

Action Taken

The University Health Board developed BCUHB Procedure MD23 to mitigate risks due to failure to act on diagnostic results, based on NPSA 16 guidance, and approved at the end of 2016. An electronic reporting system (CHAI Ping app) is being developed to provide alerts to clinicians when histology reports are authorised for viewing. (AI summary)

View full response

Dear

To strengthen this process an electronic reporting system with a function to alert the requesting clinician when histology reports are authorised for viewing needs to be made available. Work has begun to develop the CHAI Ping app to provide the solution to the current gap in the WCP of 'notification' that a result is available and 'authorise and recording of action taken'. This would work with the WCP to enable the organisation to improve assurance and stop printing reports for the results in scope i.e. those available to view in the WCP The Health Board accepts that the current procedure for the dissemination of histology results can be improved hope this letter and action plan offers the required level of assurance that we are focused on taking action to address the issues raised in your letter_ Please let me know if you would like further detail on any of the areas within my response.

Report sections

Investigation and inquest

On 14 November 2016 commenced an investigation into the death of Mr Raymond Edwards, aged 69_ investigation concluded at the end of the inquest on 23 January 2017 . The conclusion of the inquest was: NARRATIVE CONCLUSION-On 24 November 2015 Mr Raymond Edwards was operated for Terminal Ileum He developed an anastomatic Ieak which was operated on December 2015 but Mr Edwards died sepsis and multi organ failure on 2 December 2015.at Ysbyty Glan Clwyd

Circumstances of the death

Mr Raymond Edwards was initially admitted to Glan Clwyd Hospital on 17 June 2015 and underwent a laparotomy for ischaemic bowel secondary to small bowel volvulus. He was discharged on 2 July 2015. Histology of the excised bowel was undertaken and revealed the rare disease amyloidosis_ This histology result was never received by the named consultant and the disease was not followed up. Mr Edwards was re admitted to Clwyd Hospital on 13 November 2015 after feeling generally unwell: On 24 November 2015 Mr Edwards was operated upon and his appendix removed and a small area of ischaemic bowel excised and a primary anastomosis_ By the date of this operation the relevant department were aware of the amilioidosis By 1 December 2015 Mr Edwards' condition rapidly deteriorated suggestive of an anastomotic leak. This was operated on December2015 but Mr Edwards continued to deteriorate and died on 2 December 2015. The medical cause of death was 1a. Multi Organ Failure, Sepsis 1b_ Anastomotic Leak (Operated December 2015) , 1c. Ischaemic Terminal Ileum (operated 24/11/2015). Il. Pulmonary Embolism (warfarinised) , Rheumatoid Arthritis (on Methotrexate) , Laparotomy for Ischaemic Small Bowel secondary to small bowel volvulus (operated 17/06/2015) , Amiloidosis _

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2017-0029
Date of report: 10 February 2017
Coroner: Nicola Jones
Coroner area: North Wales (Eastern and Central)

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: 7 Apr 2017.

Sent to

Betsi Cadwaladr University Health Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.