Source · Prevention of Future Deaths

John Rogers

Ref: 2016-0097 Date: 9 Mar 2016 Coroner: John Adrian Gittins Area: North Wales (East and Central) Responses identified: 1 / 1 View PDF

The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.

Date 9 Mar 2016
56-day deadline 4 May 2016 est.
Responses identified 1 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.
View full coroner's concerns
_ _ That the current systems in place within BCUHB are not sufficiently robust to ensure that their staff are appropriately qualified to undertake the work required of them and that their training and qualifications remain up to date_ Coroner'$ Officc; County Hall, Wynnstay Road; Ruthin, LLIS IYN Tcl 01824 708047 01824 708048 Artery being Fax

Responses

1 respondent
University Health Board
14 Mar 2016 PDF
Action Taken

The University Health Board has undertaken and completed a detailed action plan relating to Ysbyty Glan Clwyd with specific training requirements. They are strengthening systems to ensure training and qualifications remain up to date, introducing a more rigorous approach to monitoring and a supportive approach for staff training. (AI summary)

View full response
Dear Mr Gittins_ RE: Report for the Prevention of Future Deaths Inquest of John William Rogers Further to your letter dated 14th March 2016, please find below the Health Board's response to the Regulation 28 requirements which_ in this case, particularly relates to the concerns "that the current systems in place within BCUHB are not sufficiently robust to ensure that their staff are appropriately qualified to undertake the work required of them and that their training and qualification remain up to date We have focused on two clear aspects in order to respond to your concerns following this Inquest The first being the detailed action plan relating to Ysbyty Glan Clwyd and the specific training requirements relating to the Inquest and secondly, the wider application of your concern, Which is focused on the BCUHB wide training systems to ensure that all staff are appropriately qualified to undertake the work required of them and that their training and qualifications remain up to date have therefore included in the attached documents , the detailed action plan demonstrating actions which have been undertaken and completed, subsequent to the death of John William Rogers, to provide assurance relating to the training and appropriate qualifications of the staff on the unit and also for related on-call arrangements and rotas_ The second document, included within this response, provides clarity of the policy and procedure frameworks supporting training and qualifications for all staff across Health Board and covers the systems and processes which the Health Board have in place to provide assurance on the training and qualification status for all staff members. In reviewing the training framework and policies with colleagues_ there are range of actions which have been proposed and agreed within the Senior Managers and Executive Team, which will strengthen the current systems and processes to ensure training and qualifications status remain up to date (current) for the clinical area within which work_ To ensure that there are no lapses to training and qualifications; the Health Board has introduced more rigorous approach to monitoring as well as supportive and flexible approach for staff to complete their mandatory training: Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd ar Prif Weithredwr Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr Executives' Office Ysbyty Gwynedd, Penrhosgarnedd Bangor; Gwynedd LL57 2PW Gwefan: WWW:pbc cymru nhs.uk Web: www.bcu.wales nhs.uk the they

GIG Bwrdd lechyd Prifysgol CYMRU Betsi Cadwaladr NHS University Health Board WA LE $ The outcome and status of mandatory training and maintenance of core clinical skills has and will remain priority for the Health Board and is part of the Health Board's monthly performance reporting. This is actively monitored through the Clinical Accountability meetings held with each Hospital and area teams and is subsequently reported through to the Health Board. Please be assured that the Health Board is monitoring training compliance to ensure that staff are appropriately qualified to undertake their role_

Report sections

Investigation and inquest
On 31/03/2015 ! commenced an investigation into the death of John William Rogers, (DOB12.7.36 DOD 28.3.15) The investigation concluded at the end of the inquest on 08 March 2016_ The conclusion of the inquest was one of Natural Causes the Cause of Death being recorded as 1(a) Left Ventricular Failure (b) Myocardial Infarction (c) Occlusive Coronary Atheroma
Circumstances of the death
The Deceased was admitted to Glan Clwyd Hospital on the 25th of March 2015 and in the early hours of the 28th of March was found collapsed on the floor near to his bed following a cardiac arrest: In the course of the subsequent resuscitation attempts the defibrillator was set on 2 joules rather than the required 150 joules yet although this error was identified by nursing staff after around 30/40 minutes they did not advise the crash team of this_ The defibrillator was controlled at the time of this error by a member of the nursing staff who was operating the machine on a manual setting for the first time and whose Advanced Life Support qualification (obtained more than four years before) had expired the previous month
Action should be taken
In my opinion action should be taken to prevent future deaths believe you have the power to take such action

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Report details

Reference
2016-0097
Date of report
9 March 2016
Coroner
John Adrian Gittins
Coroner area
North Wales (East 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: 4 May 2016 (estimated).

Sent to

Betsi Cadwaladr University Health Board

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