Source · Prevention of Future Deaths

Pamela Conway

Ref: 2016-0309 Date: 26 Aug 2016 Coroner: John Gittins Area: North Wales (East and Central) Responses identified: 2 / 2 View PDF

Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.

Date 26 Aug 2016

56-day deadline 21 Oct 2016

Responses identified 2 of 2

Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.

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busy delay part

a5 follows That notwithstanding changes which have been made by both BCuHB and WAST , there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues_ Evidence at the inquest indicated that the problem of "patient flow" within the Maelor Hospital continues to result in delays within the Emergency Department and it is of considerable concern to me that such problems have been the subject of previous regulation 28 reports and are also within the scope of a number of ongoing inquests.

Responses

2 respondents

Welsh Ambulance Service NHS Trust NHS / Health Body

19 Oct 2016 PDF

Action Taken

The Welsh Ambulance Service NHS Trust has made progress against key actions identified in an attached action plan, with the most significant impact from the Welsh Health Circular regarding hospital handover guidance. Lessons learned from the case are being monitored through a Task and Finish Group. (AI summary)

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Dear May Mick LbcWr ( 1 Fotl 0549169

Please do not hesitate to contact me if you have any questions with regards to the action plan On a more general note look forward to meeting you and colleagues in your coronial area to discuss areas of concerns to us all as we discussed in the Summer

University Health Board

PDF

Action Planned

The University Health Board is scrutinizing two working action plans relating to the case, which will be monitored by the Quality and Safety Group. (AI summary)

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Dear Mr Olitlns Re: Rogulation 20 loftor in recpect of Pamela Conwy Further to your Regulation 28 notifications to the Health Board following the inquest 0f Pamela Conwy: The Health Board has coneidered your concerne in relation to the following issues outlined in the two notifications: Elret Regulation 28 Notiicztion Pert 1 Thet not Withstanding chenger wiich have been mede by both BCUHB end WAST, there remein Wnolly unacceptabla delaye with paliente being kept welting for long periode in embulences and ambulance resourcee consequances being unavailable for allocation to Oiner calls &8 & rasult of wnich the risk of future deaths continuas Part 2 Evidence at the inquest indicated ihat the problem of patient fiow in tne Maelor result In patlent dslsye within the Emergency Deparment and it is of considerable concem t0 ma dhat euch probleme have been ihe subjeot of previous regulation 28 reports and ar also within the scope of & number of ongoing inquesis Second Requlatinn 28 Notiiicaion Pah 1 Evdence at ihe inquest indlcated thet dlscuceiong ware faking place between dllierent deparirnente wthln BCUHE with & view io agreeing & proiocol to establish an approprlate care pathway for patlenta pragentlng {0 Ine hospltel with an Infecied prosinesie, howaver nothing had been finalised regarding tha seme: Part 2 Furtherore evidence Indlcated that although it was always Intended {hat antibiotics would be administered once Ihe patient's khee had been aspirated, {here Was & of almost twvo houre between this procedure &nd Ihe adminiciration of antibiotics (@ which wrs expleined by beirig due d0 tnomal hospital proceduras Cyielicd Gahebleath ar gyiar y Cadelryud &ttr Prlf Welthreciz / Coreapondenc? eddtese for Chelrman end Chlet Exccutea: Suydciat @welinrcawyr Executives' Oitice , Yebyty Gwynedd, Fenrhoegamedd Dangor; Gwynedd LL67 ZFW Gwofan: Wvw-pbc cymru nhsuk Wob: unwbcu,walcz nheuk WR delay delay

GIG Bwrdd lechyd Prifysgol CYMEU Betsi Cadwaladr NHS University Health Boerd Wales Therefore please find enclosed two working action plans relating to this cage. The action plans will be scrutinized by the Assistant Director or Nursing as well as the Hospital Medical Director and will be monifored by the at the Quality and Safety Group to ensure timely progress. Yourc sincerely Mr Evan Mooro Exocutive Mlodical Director Enc

Report sections

Investigation and inquest

On the 13th of November 2014 commenced an investigation into the death of Pamela June Conway (DOB 13.6.43,DOD 8.11.14). The investigation concluded at the end of the inquest on the 23rd of August 2016 and | recorded a conclusion that the death was due to natural causes which were exacerbated by delayed medical treatment

Circumstances of the death

The Circumstances of the death are that for multifactorial reasons there was a delay of around 21 hours before the deceased received antibiotics for an infected knee and that during the course of this period she went into irrecoverable septic shock_ Amongst the reasons for the above delay was the length of time it took for Mrs Conway to be discharged from the ambulance to the hospital on the 10th of October 2014. On this date the emergency department at Wrexham Maelor Hospital was extremely and despite an agreed handover time of 15 mins_ Mrs Conway waited in the ambulance for 2 hours and 50 mins. The longest waiting time on that date for a patient handover was one minute short of five hours Whilst this alone did not result in her death; it did form a of the cumulative delays by which Mrs Conway was denied the best chance of having her knee infection successfully treated and hence not going on to develop sepsis_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe your organisations have the power to take such action.

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Shared signals

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Report details

Reference: 2016-0309
Date of report: 26 August 2016
Coroner: John Gittins
Coroner area: North Wales (East and Central)

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Oct 2016.

Sent to

Betsi Cadwaladr University Health Board

Welsh Ambulance Services NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.