University Health Board
NHS / Health Body
Action Taken
The University Health Board has discontinued the practice of inserting chest drains at a 'marked' point and has purchased equipment. A task and finish group will oversee implementation and assessment across the Health Board and will report to the Quality, Safety and Experience Committee. (AI summary)
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Dear Mr Spinney, Re: Regulation 28 report _ David Robart Grifriths Thank you for your letter dated 3rd February 2017 . heairquevierecarhin concems yourtve raised within the Regulatlon 28 report following the inquest regarding the death of Mr Grifths; My responge ha8 been nformec contorclinical and managerial staff Who are able t0 advise me on the arising by concerns and pursue the improvements required as a resul, recognise that this has been # particularly difficult for Mr Grlffithe' family and / Bould Wlsh t0 ofifer them my sincere condolences on behaif 0f the Universiiy Health Board. Youwilbet aware that the Health Board underlook an interal Investigation- teincident invoiving Mr Griths, Hoich udercpok ed Iotevonsl Govaratienfoliloiheg Serious Incident reporting procedures in September 2016. concems irortera inguest elgo 0 9 erocatnesn Sepoember Zaons Yoad8 O1ce1 G orislncant in Intensive Care Medicine who Investigated the incldent: For ease 0f reference, have set out below the Health Board'& response t0 the issues You ralsed, Consideration should be glven to reviewing your procecures related to chest draln insertion and conslder Introduclng an Induction programme for &ll new medlcal and nursing staf. The UHB has considered the fIndings of the Investigation and has taken the decision to discontinue the practice 0f 'inserting chest drains at a 'marked Plerje {sckeirosss ()*69vrtextcs? icx: Chkef execlriivet Gtollif ertil Univsreliy Ioteilit Bonial. Unvss f kapiteel (f WVeie , Sheath Paik, Csnlix (F14 Axw 742 088 time Ihe Your have 4bd054 0 {iiies. Val O1s4044o
spof' and ig iniroducing a revieed procedure whereby chest drains are inserted under cirect vislon Ulrasound guidance; This was confined by the Cllnlcal Dlrector of Radiology and communicaied io senlor modical staff acios8 UHB In early January 2017 . In addition to %his, additional support from ihe Respiratory on-call team has been mada avallablo In In-hours scenario for doctors Who require gupport and are not appropriately accredlted. On the rare occasion that an oUt Of hours pleural aspiration or draln insertion Is required (e.g: for suspected pleural Infection, signiticant symptomatlc Or haemodynamic comprornise) It has been agreed that the on cali medical team should be contacted working group has been established with speclilc remit to improve fhe gafety orpatlents undergoing intercostal chest draln Insertion and tovensura Health Board8 compliance with the related British Thoracic Society guidance (Reference: Havelock T, Teoh R, Laws D, Gleeson F Pleural procedures and Thoracic Ultrasound: British Thoracic Soclety Pleural Disease Guideline 2010. Thorax; 65(suppl 2)xi161-II76), There Is representation from the Clinical Boards and radlology to consider several issues and it Is being chalred by] respiratory Physician. The use of Ultra sound guidance The training 0f staff t0 uSe these in and out of hour8 Tralning in chest draln Insertion Thls group wil also consider the requirement for specific induction In relation to chest drain insertion,on the basis , that registrars and epecialist reglstrars across speclfic specialitles are employed on the basis, that are already competent in a number %f core and essential skills, which would Include chest draln Insertion: The UHB i8 currently liaising with the Welsh Deanery on this issue In relation t0 general Induction programmes for all new medical and nursing stafif;, the Workforce and Organisational Development Department has procedures In place to asslet managers to ensure the appropriate Induction of new stafi members to an individual department and wider organisation. Staif merbers are allocated & t0 attend & corporate induction programme for organisational Induction: receive a lotler of Invltation and managers are required t0 release staff t0 attend. Senior medlcal staff are Offered an opportunity t0 attend & Senior Modical Staff Induction programme which (s coordinated by Ihe Leaming; Education and Development Department In conjunction with ihe Medical Workiorce Department: The Health Board recognises the importance Of local Indluction t0 indvidual departments In order to support new employees A local Induction checklist is available to support managers and new Sfaff in induction process: Plaase acufess corecponclenca t: Excttlilve'# Oijcc , Cerrtiff end Vale UJnivarsily Henlth Boerd, Unlvetalty ! oagltal 0f Weloe; Hoxth Perc, CarcHif CFA4 4XW 'O1s48149 key the the the they day - They tho 480856 chiel
Ieoroition labout indluction procecures Is avallable on the Healih Board'& web site whlch can be acceased via the link below: hip llwww_Gardingrilvaleuhh walea nhs uishnclyctlon It is recognised that requirements for content of local induction signiticantly acrosethe many dopariments Ovihin 0eOlealilugoiod Wilovary Diecical staff;, local induction processes are overseon by the relevant Directorate 8 Clinicel Director; by senior Directorate steftf for new nurse employees and 80 forth, deponding on the staff discipline; My resporse t0 concems that you have raised wlll be shared with all Clinicai Boards with & request that seek assurance from thelr Directorates that appropriate induction processes are Gn place across the Health Board Conslderation should be Qiven t0 Ihe acquisition 0f appropriate ulerasound equipment fo allow real time guidance Of cheordrain insertion; pleural procedures and dlagnostics am pleased to be able t0 advlse you thate pcdrfioian and Respiratory Gead B ou lso coordlnaled tho puCoasgtoriwo additional ultrasound machlnes suitable for use in these clinical circumstances The purchase has been supported by the Health Board'& Medical Equipment Group and Procurement Department Codsloleearior should be given to an ulkrasound tralning = and governance structure for all practitioners who are programme the insertion of intercostal drains responsible for Iie of paramount Importance that staff are appropriately trained to Intercostal drains the ultrasound equipmerpihateh8 bied} pUichesed. basoke thoracic ultrasound training course was provlded to the Cardiothoracic Directorate On 16" March 2017 with suppont Davies and the manufacturer of purchased equipment_ It i8 recognised that arrangements for ongoing and issessment musi be in place across the 9agh Boand and Gogrwiof oece implemented and overseen by the tak and group. hibe group wli report to te Quality: Safety and Experience Committee Which receives informatlon regarding Regulation 28 - Preventlon of Future Deaths Reports In order t0 ensure the necessary progreeves beirgj madee Sldfortely, tke Weleh Goverment issued a Patient Safety Notice PSNO34 Propporting the Introduction orthe Netional SafetyeStandards fof (rVASNO Cootaidtren' in September 2016,' Welsh NHS organisations grorrequireve {o complete the necessary actions on this safely notice by Septernber 2007. Mse %khrss GYIASp )ksrv? io: Clini executhn (fex: €araHRf aini} Vniv lely Henla FJoarW , Valvaialny {xDyloi Wrlon Howin Pork, CnnHi GJA4XW 01s48630 the nursing the thoy using from the iraining finish ( A8Us == Vals
The notice can be accossed via Ihe website link which is provided here for yoUi" roference: hip IWW padlenteeieiv Walee nh" Ukleiteaplueldocunents/L OAIESN4s4%20 Suppoling?2Ointrocluctiou?ZDOf"72ONSSIEg pdt A simllar safety notice was published In NHS England in Septernber 2015 . Resources are therefora developed for use in NHS England {hat can be adapted and adopted for u88 in NHS Wales. The task and finish group intends to explore the Implementation of a saiety checklist ior chesf drain inserion; An example 0f such a tool, developed by the Intenslve Care Society , is atteched In Appendix 1. hope that the information set out In this lotter provldes you with the assuranco that the Health Board has = considered the Issues raised &8 & consequence of the investigation; Inquest and your letter of 3rd February 2017, and has taken approprlato action In response.
spof' and ig iniroducing a revieed procedure whereby chest drains are inserted under cirect vislon Ulrasound guidance; This was confined by the Cllnlcal Dlrector of Radiology and communicaied io senlor modical staff acios8 UHB In early January 2017 . In addition to %his, additional support from ihe Respiratory on-call team has been mada avallablo In In-hours scenario for doctors Who require gupport and are not appropriately accredlted. On the rare occasion that an oUt Of hours pleural aspiration or draln insertion Is required (e.g: for suspected pleural Infection, signiticant symptomatlc Or haemodynamic comprornise) It has been agreed that the on cali medical team should be contacted working group has been established with speclilc remit to improve fhe gafety orpatlents undergoing intercostal chest draln Insertion and tovensura Health Board8 compliance with the related British Thoracic Society guidance (Reference: Havelock T, Teoh R, Laws D, Gleeson F Pleural procedures and Thoracic Ultrasound: British Thoracic Soclety Pleural Disease Guideline 2010. Thorax; 65(suppl 2)xi161-II76), There Is representation from the Clinical Boards and radlology to consider several issues and it Is being chalred by] respiratory Physician. The use of Ultra sound guidance The training 0f staff t0 uSe these in and out of hour8 Tralning in chest draln Insertion Thls group wil also consider the requirement for specific induction In relation to chest drain insertion,on the basis , that registrars and epecialist reglstrars across speclfic specialitles are employed on the basis, that are already competent in a number %f core and essential skills, which would Include chest draln Insertion: The UHB i8 currently liaising with the Welsh Deanery on this issue In relation t0 general Induction programmes for all new medical and nursing stafif;, the Workforce and Organisational Development Department has procedures In place to asslet managers to ensure the appropriate Induction of new stafi members to an individual department and wider organisation. Staif merbers are allocated & t0 attend & corporate induction programme for organisational Induction: receive a lotler of Invltation and managers are required t0 release staff t0 attend. Senior medlcal staff are Offered an opportunity t0 attend & Senior Modical Staff Induction programme which (s coordinated by Ihe Leaming; Education and Development Department In conjunction with ihe Medical Workiorce Department: The Health Board recognises the importance Of local Indluction t0 indvidual departments In order to support new employees A local Induction checklist is available to support managers and new Sfaff in induction process: Plaase acufess corecponclenca t: Excttlilve'# Oijcc , Cerrtiff end Vale UJnivarsily Henlth Boerd, Unlvetalty ! oagltal 0f Weloe; Hoxth Perc, CarcHif CFA4 4XW 'O1s48149 key the the the they day - They tho 480856 chiel
Ieoroition labout indluction procecures Is avallable on the Healih Board'& web site whlch can be acceased via the link below: hip llwww_Gardingrilvaleuhh walea nhs uishnclyctlon It is recognised that requirements for content of local induction signiticantly acrosethe many dopariments Ovihin 0eOlealilugoiod Wilovary Diecical staff;, local induction processes are overseon by the relevant Directorate 8 Clinicel Director; by senior Directorate steftf for new nurse employees and 80 forth, deponding on the staff discipline; My resporse t0 concems that you have raised wlll be shared with all Clinicai Boards with & request that seek assurance from thelr Directorates that appropriate induction processes are Gn place across the Health Board Conslderation should be Qiven t0 Ihe acquisition 0f appropriate ulerasound equipment fo allow real time guidance Of cheordrain insertion; pleural procedures and dlagnostics am pleased to be able t0 advlse you thate pcdrfioian and Respiratory Gead B ou lso coordlnaled tho puCoasgtoriwo additional ultrasound machlnes suitable for use in these clinical circumstances The purchase has been supported by the Health Board'& Medical Equipment Group and Procurement Department Codsloleearior should be given to an ulkrasound tralning = and governance structure for all practitioners who are programme the insertion of intercostal drains responsible for Iie of paramount Importance that staff are appropriately trained to Intercostal drains the ultrasound equipmerpihateh8 bied} pUichesed. basoke thoracic ultrasound training course was provlded to the Cardiothoracic Directorate On 16" March 2017 with suppont Davies and the manufacturer of purchased equipment_ It i8 recognised that arrangements for ongoing and issessment musi be in place across the 9agh Boand and Gogrwiof oece implemented and overseen by the tak and group. hibe group wli report to te Quality: Safety and Experience Committee Which receives informatlon regarding Regulation 28 - Preventlon of Future Deaths Reports In order t0 ensure the necessary progreeves beirgj madee Sldfortely, tke Weleh Goverment issued a Patient Safety Notice PSNO34 Propporting the Introduction orthe Netional SafetyeStandards fof (rVASNO Cootaidtren' in September 2016,' Welsh NHS organisations grorrequireve {o complete the necessary actions on this safely notice by Septernber 2007. Mse %khrss GYIASp )ksrv? io: Clini executhn (fex: €araHRf aini} Vniv lely Henla FJoarW , Valvaialny {xDyloi Wrlon Howin Pork, CnnHi GJA4XW 01s48630 the nursing the thoy using from the iraining finish ( A8Us == Vals
The notice can be accossed via Ihe website link which is provided here for yoUi" roference: hip IWW padlenteeieiv Walee nh" Ukleiteaplueldocunents/L OAIESN4s4%20 Suppoling?2Ointrocluctiou?ZDOf"72ONSSIEg pdt A simllar safety notice was published In NHS England in Septernber 2015 . Resources are therefora developed for use in NHS England {hat can be adapted and adopted for u88 in NHS Wales. The task and finish group intends to explore the Implementation of a saiety checklist ior chesf drain inserion; An example 0f such a tool, developed by the Intenslve Care Society , is atteched In Appendix 1. hope that the information set out In this lotter provldes you with the assuranco that the Health Board has = considered the Issues raised &8 & consequence of the investigation; Inquest and your letter of 3rd February 2017, and has taken approprlato action In response.