Source · Prevention of Future Deaths
Esther Jones
Ref: 2014-0296
Date: 2 Jul 2014
Coroner: John Gittins
Area: North Wales (East & Central)
Responses identified: 0 / 1
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Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.
Date
2 Jul 2014
56-day deadline
27 Aug 2014 est.
Responses identified
0 of 1
Coroner's concerns
Significant delays in completing Serious Incident Reviews (SIRs) and disseminating lessons learned prevent timely improvements and risk further patient harm.
View full coroner's concerns
During the course of the inquest; evidence given by the family of the Deceased and by representatives of BCUHB established that there had been a substantial in the completion of the SIR and the sharing of this with myself as Coroner ad with the family of Deceased. am concerned that in cases where Serious Incident Reviews are taken, any delay in the completion of the same could pose a risk to other patients as lessons learnt from the same may not be disseminated to staff in a timely manner and further that the conclusion of my own investigations may be also be delayed, potentially limiting the effectiveness of a Regulation 28 report; That unless steps are taken to improve the process by which SIRs are conducted and completed, then this could pose continuing risks to others and may lead to future deaths being delay the
Report sections
Investigation and inquest
On the 18th of March 2013 commenced an investigation into the death of Esther Jane Jones (DOB 30.08.1919 DOD 30.03.2013). The investigation concluded at the end of the inquest on the 18"h of June 2014 and recorded a conclusion of Natural Causes with the cause of death 1(a) Pulmonary Embolus due to 1(b) Phlebothrombosis (Right Leg)
Circumstances of the death
The Circumstances of the death are that the Deceased had died at the Maelor Hospital, Wrexham and although it was established that the death was ultimately due to Natural Causes there had been a Serious Incident Review conducted by BCUHB following the death as a result of concerns arising in relation to missed medication:
Action should be taken
In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action.
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Report details
- Reference
- 2014-0296
- Date of report
- 2 July 2014
- Coroner
- John Gittins
- Coroner area
- North Wales (East & Central)
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Aug 2014 (estimated).
Sent to
- Betsi Cadwaladr University Health Board