Source · Prevention of Future Deaths

Gwilym Pugh Jones

Ref: 2013-0239 Date: 25 Sep 2013 Coroner: John Gittins Area: North Wales (East and Central) Responses identified: 1 / 1 View PDF

Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.

Date 25 Sep 2013

56-day deadline 20 Nov 2013

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.

View full coroner's concerns

(1) Tests were not conducted despite being required by a clinician and this resulted in a missed opportunity to provide a diagnosis and treatment.

Responses

1 respondent

Mersey Care NHS Foundation Trust NHS / Health Body

14 Mar 2014 PDF

Action Taken

• The Corporate Governance Team was tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date. • Three policies are subject to fundamental review; this process will be completed by 31st March 2014. (AI summary)

View full response

Dear Mr Rebello, Thank you for raising your concerns about the fact that Trust Policy had not been updated for some time and therefore was not representative of current practice. can confirm that the Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date_ Three policies are subject to fundamental review; this process will be completed by 31st March 2014. Between November 2013 and 12th February 2014, 50 policies have been reviewed and updated: can confirm that the policy that provided you with concern at the Inquest on 11th October 2013 was one of the first to be reviewed and updated. If can provide any further information, please do not hesitate to contact me at the above address_

Report sections

Investigation and inquest

On the 19th of April 2013 I commenced an investigation into the death of Gwilym Pugh Jones (DOB 24.2.40, DOD 16.4.13). The investigation concluded at the end of the inquest on the 19th of September 2013. The conclusion of the inquest was Accidental Death and the medical cause of death was 1(a) Sepsis 1(b) Peritonitis and Toxic Mega Colon 1(c) Pseudomembranous Colitis (Clostridium Difficile Infection) 2 Diabetes Mellitus and Lacunar Anterior Circulation Stroke.

Circumstances of the death

1. The Deceased had been admitted to the Wrexham Maelor Hospital on the 14th of March 2013 due to an apparent stroke. Whilst a patient at this hospital he developed symptoms which were suggestive of the Clostridium Difficile infection and on the 11th of April by an attending clinician that a stool sample be sent for analysis. This was not done.
2. At the final inquest hearing evidence was given by regarding the treatment of Mr Jones and he was unable to account for the failure of obtaining and testing a stool sample and he indicated that it is possible that the final outcome may have been different had this condition been diagnosed and treated sooner.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2013-0239
Date of report: 25 September 2013
Coroner: John 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: 20 Nov 2013.

Sent to

Betsi Cadwaladr University Health Board

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.