Nesta Jones
PFD Report
All Responded
Ref: 2024-0110
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 24 Apr 2024
Response Status
Responses
1 of 1
56-Day Deadline
24 Apr 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
a. Nesta Jones was seen by a number of orthopaedic doctors of varying grades including consultants. There was a concern during the evidence that junior doctors may not reach a different opinion to their consultant colleagues where the consultants have seen patients prior, and that this opinion is then followed through the patient’s journey. If junior doctors are not encouraged to challenge or discuss their findings (which may be different) to their consultant colleagues or have professional discussions, then there is a risk of missing diagnoses.
b. The family wrote a detailed urgently marked letter to the Chief Executive on 3 May 2017 whilst Nesta was still in hospital. This requested consideration by him of her care as ‘a matter of life or death urgency’. There was no response. The Health Board did not have adequate and appropriate systems and processes for dealing with such complaints and concerns.
c. There was no full investigation undertaken by the Health Board into Nesta’s death other than a desktop report, the quality of which was questionable, as the Police were investigating. This means that there were no formal considerations as to immediate actions or learning required to reduce harm and the risk of death. In oral evidence I was informed that there is a new governance process being considered and likely to be in force by April 2024. I have made previous Reports on this precise point and yet the new and improved process is still not in place.
b. The family wrote a detailed urgently marked letter to the Chief Executive on 3 May 2017 whilst Nesta was still in hospital. This requested consideration by him of her care as ‘a matter of life or death urgency’. There was no response. The Health Board did not have adequate and appropriate systems and processes for dealing with such complaints and concerns.
c. There was no full investigation undertaken by the Health Board into Nesta’s death other than a desktop report, the quality of which was questionable, as the Police were investigating. This means that there were no formal considerations as to immediate actions or learning required to reduce harm and the risk of death. In oral evidence I was informed that there is a new governance process being considered and likely to be in force by April 2024. I have made previous Reports on this precise point and yet the new and improved process is still not in place.
Responses
Betsi Cadwaladr University Health Board is issuing a Safety Alert by the end of April 2024 to support the improvement of listening to differing professional views, including those from junior clinicians. They are also commissioning a new digital system for incidents and complaints and developing a new integrated framework to cover incidents, complaints, and mortality, with the Chief Executive personally overseeing this work.
AI summary
View full response
Dear Ms Robertson,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Nesta Jones
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 28 February 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Nesta Jones.
I would like to begin by offering my deepest condolences to the family of Mrs Jones. On behalf of the Health Board, I apologise to them for the failures in the care of Mrs Jones. I will be writing to them directly to offer our apologies and to offer to meet.
In the notice, you highlighted your concerns about the complaint and incident processes and your concerns about the ability for junior medical staff to challenge already established clinical decisions.
On the issue of medical challenge, I can confirm the Health Board encourages full multi- disciplinary working and actively encourages all staff, regardless of grade or seniority, to raise concerns or differing professional views. All doctors have a duty to listen and act on concerns. Our clinical standards, in accordance with national best practice, establish robust multi-disciplinary team meetings in specialties to review cases collectively. This does however need to be balanced against the responsibility of a medical consultant to make decisions as the most senior clinician in charge of a patient’s care.
We are issuing a Safety Alert to share the learning from this case and to highlight and support the improvement of listening to differing professional views and concerns including those from more junior clinicians. This will be shared across the organisation by the end of April 2024.
Since Mrs Jones’ death in 2017, we implemented a revised approach for staff to raise concerns outside of their team, if necessary. This new approach, called Speak out Safely, was launched in 2021 and allows any member of staff to raise concerns with a Speak out Safely Guardian or through an anonymous online messaging system where they can
Dyddiad / Date: 23 April 2024 Kate Robertson HM Senior Coroner North Wales (West) Coroner's Office Shirehall Street CAERNARFON Gwynedd LL55 1SH Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
reach senior staff. Whilst we aspire to a culture where concerns are raised and resolved locally, this new system provides an important safety net.
In relation to the complaint process, I can confirm that since Mrs Jones’ death the process in the Complaints Team has now changed. A new Complaints Procedure was introduced in March 2022. This procedure includes an escalation process. However, I acknowledge that further improvement is still needed and we are currently undertaking a full review of the complaint process alongside the review of the incident process detailed below. We will create a new, integrated framework that covers incidents, complaints and mortality. This work is underway at present with a view to completion in the next two months.
In addition, as mentioned at the inquest, the Health Board has also launched a new service to allow patients or relatives to escalate their clinical concerns, called Call 4 Concern. The Call 4 Concern Service was launched in Ysbyty Gwynedd during 2022 and following a pilot is now being rolled out at our other general hospital sites this year.
The Call 4 Concern Service enables patients at the hospital and their families to call for immediate help and advice if they are worried that the health care team has not recognised their changing condition. The service is run by the Acute Intervention Team, a group of highly skilled and experienced Advanced Nurse Practitioners available 24/7 to support ward teams in the care of acutely ill patients. Upon receiving a Call 4 Concern, a member of the Acute Intervention Team visits and reviews the patient on the ward. After assessing the situation and liaising with the medical team and other healthcare professionals as needed, the team will ensure the necessary intervention is implemented.
Finally, in relation to the incident process, you will be aware of the Chief Executive’s and my own personal intervention in this area as discussed at our most recent meeting and as outlined in previous letters.
The Chief Executive is now personally driving this work which will include a new, integrated framework that covers incidents, complaints and mortality as I have detailed above. The Chief Executive is also personally overseeing performance in relation to overdue incidents and complaints with that area being escalated for close executive scrutiny. As a result, we expect to see significant improvement in the process, and the quality and timeliness of investigations, over the coming months as changes are implemented. We are also engaging the support of the NHS Wales National Executive quality team to support us in this improvement work.
The new framework will include an explicit reference to the national joint memorandum of understanding between the NHS and police, which covers situations where there are concurrent investigations. This will ensure that we operate in accordance with these national standards.
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed.
We would be happy to meet with you to discuss any issue in further detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family of Mrs Jones and I reiterate my sincere apologies to them for the failures in the standard of care.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Nesta Jones
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 28 February 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Nesta Jones.
I would like to begin by offering my deepest condolences to the family of Mrs Jones. On behalf of the Health Board, I apologise to them for the failures in the care of Mrs Jones. I will be writing to them directly to offer our apologies and to offer to meet.
In the notice, you highlighted your concerns about the complaint and incident processes and your concerns about the ability for junior medical staff to challenge already established clinical decisions.
On the issue of medical challenge, I can confirm the Health Board encourages full multi- disciplinary working and actively encourages all staff, regardless of grade or seniority, to raise concerns or differing professional views. All doctors have a duty to listen and act on concerns. Our clinical standards, in accordance with national best practice, establish robust multi-disciplinary team meetings in specialties to review cases collectively. This does however need to be balanced against the responsibility of a medical consultant to make decisions as the most senior clinician in charge of a patient’s care.
We are issuing a Safety Alert to share the learning from this case and to highlight and support the improvement of listening to differing professional views and concerns including those from more junior clinicians. This will be shared across the organisation by the end of April 2024.
Since Mrs Jones’ death in 2017, we implemented a revised approach for staff to raise concerns outside of their team, if necessary. This new approach, called Speak out Safely, was launched in 2021 and allows any member of staff to raise concerns with a Speak out Safely Guardian or through an anonymous online messaging system where they can
Dyddiad / Date: 23 April 2024 Kate Robertson HM Senior Coroner North Wales (West) Coroner's Office Shirehall Street CAERNARFON Gwynedd LL55 1SH Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
reach senior staff. Whilst we aspire to a culture where concerns are raised and resolved locally, this new system provides an important safety net.
In relation to the complaint process, I can confirm that since Mrs Jones’ death the process in the Complaints Team has now changed. A new Complaints Procedure was introduced in March 2022. This procedure includes an escalation process. However, I acknowledge that further improvement is still needed and we are currently undertaking a full review of the complaint process alongside the review of the incident process detailed below. We will create a new, integrated framework that covers incidents, complaints and mortality. This work is underway at present with a view to completion in the next two months.
In addition, as mentioned at the inquest, the Health Board has also launched a new service to allow patients or relatives to escalate their clinical concerns, called Call 4 Concern. The Call 4 Concern Service was launched in Ysbyty Gwynedd during 2022 and following a pilot is now being rolled out at our other general hospital sites this year.
The Call 4 Concern Service enables patients at the hospital and their families to call for immediate help and advice if they are worried that the health care team has not recognised their changing condition. The service is run by the Acute Intervention Team, a group of highly skilled and experienced Advanced Nurse Practitioners available 24/7 to support ward teams in the care of acutely ill patients. Upon receiving a Call 4 Concern, a member of the Acute Intervention Team visits and reviews the patient on the ward. After assessing the situation and liaising with the medical team and other healthcare professionals as needed, the team will ensure the necessary intervention is implemented.
Finally, in relation to the incident process, you will be aware of the Chief Executive’s and my own personal intervention in this area as discussed at our most recent meeting and as outlined in previous letters.
The Chief Executive is now personally driving this work which will include a new, integrated framework that covers incidents, complaints and mortality as I have detailed above. The Chief Executive is also personally overseeing performance in relation to overdue incidents and complaints with that area being escalated for close executive scrutiny. As a result, we expect to see significant improvement in the process, and the quality and timeliness of investigations, over the coming months as changes are implemented. We are also engaging the support of the NHS Wales National Executive quality team to support us in this improvement work.
The new framework will include an explicit reference to the national joint memorandum of understanding between the NHS and police, which covers situations where there are concurrent investigations. This will ensure that we operate in accordance with these national standards.
I hope this letter sets out for you the actions we have taken to ensure the concerns raised by yourself are being addressed.
We would be happy to meet with you to discuss any issue in further detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family of Mrs Jones and I reiterate my sincere apologies to them for the failures in the standard of care.
Report Sections
Investigation and Inquest
On 11 May 2017 an investigation was commenced into the death of Nesta Jones (DOB 9 July 1939) who died on 8 May 2017. The investigation concluded at the end of the inquest on 28 February 2024. A narrative conclusion was recorded with the cause of death as:-
1a. Bronchopneumonia 1b. Septic arthritis 2. Immunosuppression and rheumatoid arthritis
1a. Bronchopneumonia 1b. Septic arthritis 2. Immunosuppression and rheumatoid arthritis
Circumstances of the Death
The circumstances of the death are as follows :-
Nesta Jones had been in hospital for 39 days at the point she died on 8 May 2017 at Ysbyty Gwynedd. She was admitted by a GP with suspected septic arthritis of a prosthetic left knee on 31 May 2017. She did not undergo aspiration despite it being indicated by Hospital guidelines, until 5 May 2017, at which point she succumbed to the condition, deteriorated and died. Whilst she was under the care of the physicians primarily and whilst she was referred to a number of orthopaedic doctors with suspected septic arthritis, they did not consider septic arthritis and no aspiration and/or washout was undertaken until 5 May 2017, by which time her condition was irrecoverable.
Nesta Jones had been in hospital for 39 days at the point she died on 8 May 2017 at Ysbyty Gwynedd. She was admitted by a GP with suspected septic arthritis of a prosthetic left knee on 31 May 2017. She did not undergo aspiration despite it being indicated by Hospital guidelines, until 5 May 2017, at which point she succumbed to the condition, deteriorated and died. Whilst she was under the care of the physicians primarily and whilst she was referred to a number of orthopaedic doctors with suspected septic arthritis, they did not consider septic arthritis and no aspiration and/or washout was undertaken until 5 May 2017, by which time her condition was irrecoverable.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.