Source · Prevention of Future Deaths

Robert Jones

Ref: 2014-0190 Date: 20 Mar 2014 Coroner: Jonathan Layton Area: Carmarthenshire and Pembrokeshire Responses identified: 1 / 1 View PDF

CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.

Date 20 Mar 2014

56-day deadline 15 May 2014 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.

View full coroner's concerns

The MATTERS OF CONCERN is as follows:

That when a CT scan is performed the results should be made available promptly to the departments involved in the care of the patient and where appropriate the results should be acted upon without delay and within a reasonable time-scale.

Responses

1 respondent

Response

PDF

Action Planned

The Radiology department will sample emergency CT scan report times. All staff will be reminded to document review of test results, and verbal results. A report on these actions will be presented to the Health Board's Putting Things Right Committee in September. (AI summary)

View full response

Dear Mr Layton Inquest into the death of Robert Erryl Jones Thank you for your letter received by this office on March 2014, enclosing a report pursuant to Regulation 28 of the Coroners (investigations) Regulations
2013. Please accept my apologies for the delay in responding to your letter. The Health Board fully recognises the need to ensure CT scan results should be made available promptly and will ensure that this is routinely monitored. The Radiology department will be undertaking sampling of the scan to report time for emergency CT scans AlI staff will be reminded of the need to ensure that the results of diagnostic test that is requested must be reviewed by the clinical team responsible for requesting the test: It must be documented in the patient's notes that the results have been reviewed and any resultant action recorded_ test results which are given verbally , as maybe the case in an emergency situation, must also be appropriately documented in the patient record. We will also ensure that where patients maybe under the care of several different clinical teams that test results are made available to any members of those teams: The Medical Director of the Health Board will also be including this information in her regular updates to all clinical staff. Swyddfeydd Corfforaethol, Adeilad Ystwyth; Corporate Offices, Ystwyth Building Cadeirydd / Chair Hafan Derwen , Parc Dewi Sant, Heol Ffynnon Job; Hafan Derwen, St Davids Park, Job's Well Road, Mrs Bernardine Rees OBE Caerfyrddin; Sir Gaerfyrddin, SA31 3BB Carmarthen, Carmarthenshire, SA31 3BB Prif WeithredwriChief Executive Mrs Karen Howell Bwrdd lechyd Prifysgol Hywel Dda yw enw gweithredol Bwrdd lechyd Lleol Prifysgol Hywel Dda Hywel Dda University Health Board is the operational name of Hywel Dda University Local Health Board Mae Bwrdd lechyd Prifysgol Hywel Dda yn amgylchedd di-fwg Hywel Dda University Health Board operates smoke free environment 27th any Any

I confirm that a report on these actions will be presented to the Health Board's Putting Things Right Committee in September. I will write to you further with an update following this meeting: If you require any further information in the meantime, please do not hesitate to contact me

Report sections

Investigation and inquest

On 14th May 2013 I commenced an investigation into the death of Robert Erryl Jones then aged 62. The investigation concluded at the end of the inquest on 18th March 2014. The conclusion of the inquest was a narrative conclusion namely that the deceased had died as a result of complications following necessary bowel surgery. The medical cause of death was: 1(a) multi-organ failure 1(b) peritonitis 1(c) post surgery for bowel cancer

Circumstances of the death

(1) Mr Jones was admitted to Glangwili Hospital on 21st March 2013 for a bowel operation which was undertaken the following day. Mr Jones remained in hospital following the operation. (2) Due to his declining health an emergency CT scan was arranged for the 8th May 2013. (3) There was an unreasonable delay in making the results of the CT scan available to the ITU and Surgical teams involved in Mr Jones’ care. The report was not written up for some considerable time after the scan. (4) When the results were made available there was a further unreasonable delay on the part of the ITU and Surgical teams in acting upon those results. (5) This led to a significant delay in further surgery being performed. (6) It became evident during the course of the inquest that this was not an isolated incident and this failure to pass over and act on CT scan results continues to occur.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2014-0190
Date of report: 20 March 2014
Coroner: Jonathan Layton
Coroner area: Carmarthenshire and Pembrokeshire

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: 15 May 2014 (estimated).

Sent to

West Wales General Hospital Glangwili Carmarthen

Part of a series

2 reports

2015-0018 2/3

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.