Jennifer Trigger
PFD Report
All Responded
Ref: 2024-0116
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 26 Apr 2024
Response Status
Responses
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56-Day Deadline
26 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
The MATTER OF CONCERN is as follows. –
There was a miscommunication or misunderstanding when a ward nurse bleeped a junior doctor with a view to action being taken in relation to the administration of the beriplex infusion. This resulted in a delay in the doctor attending as she did not prioritise a task which was time critical and the subsequent delays resulted in an unrecoverable deterioration in the patient’s condition.
Evidence was received in the course of the inquest that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
as to work requirements and hence impacted upon prioritisation of tasks and therefore potential delays, the effects of which (as in this case) could be catastrophic in terms of patient safety. Evidence was also given that alternative systems existed that had the potential for mitigating or eliminating such risk by way of the electronic transfer of information and requests to doctors.
There was a miscommunication or misunderstanding when a ward nurse bleeped a junior doctor with a view to action being taken in relation to the administration of the beriplex infusion. This resulted in a delay in the doctor attending as she did not prioritise a task which was time critical and the subsequent delays resulted in an unrecoverable deterioration in the patient’s condition.
Evidence was received in the course of the inquest that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN
as to work requirements and hence impacted upon prioritisation of tasks and therefore potential delays, the effects of which (as in this case) could be catastrophic in terms of patient safety. Evidence was also given that alternative systems existed that had the potential for mitigating or eliminating such risk by way of the electronic transfer of information and requests to doctors.
Responses
The Health Board has upgraded its paging system at two hospitals and is piloting an integrated critical messaging application, with a third hospital upgrade due in approximately four weeks. They have also restricted bleep system use out of hours at Wrexham Maelor Hospital and mandated daily ward huddles, with a Safety Alert planned for issuance by end of April 2024.
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Dear Mr Gittins,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Jennifer Ann Trigger
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 01 March 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Mrs Jennifer Trigger.
I would like to begin by offering my deepest condolences to the family and friends of Mrs Trigger and on behalf of the Health Board I apologise to them for the failures that were identified during the inquest.
In the notice, you highlighted your concerns that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding leading to a patient safety risk.
In response, I asked our Digital, Data and Technology Department to provide me with assurance on their improvement plans, which I have summarised below.
The Health Board has been working on a paging system replacement and upgrade project for 12 months.
The project involves the replacement of existing on-site paging at Ysbyty Gwynedd in Bangor with an integrated critical messaging service, as part of an overall solution with Ysbyty Glan Clwyd in Bodelwyddan and Wrexham Maelor Hospital.
This includes a technical refresh to upgrade the existing Multitone iMessage critical messaging services across Ysbyty Glan Clwyd and Wrexham Maelor Hospital and to integrate services at Ysbyty Gwynedd.
Ysbyty Glan Clwyd and Wrexham Maelor Hospital were upgraded on 20 March 2024, and the go live at Ysbyty Gwynedd will be in approximately 4 weeks.
Dyddiad / Date: 26 April 2024 John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
Paging systems have always been used (and still are) for critical paging for 2222 emergency and urgent calls. It is a proven and reliable system for getting hold of and delivering fast bleeps to those critical teams who need to respond to an emergency.
The new Multitone iMessage critical messaging system will improve resilience and will provide standardisation across the 3 general hospitals and switchboards, and will allow for inter-site paging and cross cover arrangements.
The ongoing improvements in our systems will improve on site communication for staff to support patient referral, transfers, treatment and discharge and improve efficiencies. A number of technical options are being tested to achieve this, with the testing informing a decision on the specific future solution. These options include WiFi telephones (being tested with ward managers and matrons at Ysbyty Gwynedd) and smart phone devices with the Microsoft Teams and Cisco apps to enable calls and instant messaging through our network (being tested with 34 medical staff in Ysbyty Gwynedd). As with any new technology, it is vital we test the options with front line clinicians to inform the best solution and to ensure patient safety.
We also recognise the issue of communicating important clinical and patient safety information and tasks goes beyond technology, and to that end we will be issuing a Safety Alert across the organisation to highlight the learning from this case. This alert will be issued by the end of April 2024.
We have also taken other action to improve patient safety whilst a technical solution is implemented. At Wrexham Maelor Hospital, the use of the bleep system out of hours has been restricted to four key areas to reduce the load and distraction on junior doctors. These four areas are deteriorating patients, deceased patients, fallen patients and time critical medication. All other tasks now wait for the junior doctor to circulate the wards. The site have also mandated 3pm ward huddles across all wards so that junior doctors and nursing teams can assess what tasks need doing in the 2 hours before the end of the in hours working day, reducing the out of hours workload and urgency. These improvement have been shared with the medical directors for our other general hospital sites.
I hope this letter sets out for you the actions we are taking to ensure the concerns you raised are being addressed.
We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family and friends of Mrs Trigger for their loss and I reiterate our apologies to them for the concerns identified at inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Jennifer Ann Trigger
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 01 March 2024, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest into the death of Mrs Jennifer Trigger.
I would like to begin by offering my deepest condolences to the family and friends of Mrs Trigger and on behalf of the Health Board I apologise to them for the failures that were identified during the inquest.
In the notice, you highlighted your concerns that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding leading to a patient safety risk.
In response, I asked our Digital, Data and Technology Department to provide me with assurance on their improvement plans, which I have summarised below.
The Health Board has been working on a paging system replacement and upgrade project for 12 months.
The project involves the replacement of existing on-site paging at Ysbyty Gwynedd in Bangor with an integrated critical messaging service, as part of an overall solution with Ysbyty Glan Clwyd in Bodelwyddan and Wrexham Maelor Hospital.
This includes a technical refresh to upgrade the existing Multitone iMessage critical messaging services across Ysbyty Glan Clwyd and Wrexham Maelor Hospital and to integrate services at Ysbyty Gwynedd.
Ysbyty Glan Clwyd and Wrexham Maelor Hospital were upgraded on 20 March 2024, and the go live at Ysbyty Gwynedd will be in approximately 4 weeks.
Dyddiad / Date: 26 April 2024 John Gittins HM Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN Bloc 5, Llys Carlton, Parc BusnesLlanelwy, Llanelwy, LL17 0JG
---------------------------------- Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG
Paging systems have always been used (and still are) for critical paging for 2222 emergency and urgent calls. It is a proven and reliable system for getting hold of and delivering fast bleeps to those critical teams who need to respond to an emergency.
The new Multitone iMessage critical messaging system will improve resilience and will provide standardisation across the 3 general hospitals and switchboards, and will allow for inter-site paging and cross cover arrangements.
The ongoing improvements in our systems will improve on site communication for staff to support patient referral, transfers, treatment and discharge and improve efficiencies. A number of technical options are being tested to achieve this, with the testing informing a decision on the specific future solution. These options include WiFi telephones (being tested with ward managers and matrons at Ysbyty Gwynedd) and smart phone devices with the Microsoft Teams and Cisco apps to enable calls and instant messaging through our network (being tested with 34 medical staff in Ysbyty Gwynedd). As with any new technology, it is vital we test the options with front line clinicians to inform the best solution and to ensure patient safety.
We also recognise the issue of communicating important clinical and patient safety information and tasks goes beyond technology, and to that end we will be issuing a Safety Alert across the organisation to highlight the learning from this case. This alert will be issued by the end of April 2024.
We have also taken other action to improve patient safety whilst a technical solution is implemented. At Wrexham Maelor Hospital, the use of the bleep system out of hours has been restricted to four key areas to reduce the load and distraction on junior doctors. These four areas are deteriorating patients, deceased patients, fallen patients and time critical medication. All other tasks now wait for the junior doctor to circulate the wards. The site have also mandated 3pm ward huddles across all wards so that junior doctors and nursing teams can assess what tasks need doing in the 2 hours before the end of the in hours working day, reducing the out of hours workload and urgency. These improvement have been shared with the medical directors for our other general hospital sites.
I hope this letter sets out for you the actions we are taking to ensure the concerns you raised are being addressed.
We would be happy to meet with you and discuss our plans in more detail, or provide further information and assurance should that be helpful.
Once again, I offer my deepest condolences to the family and friends of Mrs Trigger for their loss and I reiterate our apologies to them for the concerns identified at inquest.
Report Sections
Investigation and Inquest
On the 28th of September 2020 I commenced an investigation into the death of Jennifer Ann Trigger (DOB 27.12.48 DOD 31.1.20). The investigation concluded at the end of the inquest on the 29th of February 2024. The cause of death was recorded as being due to 1(a) Extensive intra-cranial bleed 2. Warfarin Therapy and the conclusion of the inquest was that of natural causes contributed by neglect.
Circumstances of the Death
On the evening of the 29th of January 2020, the deceased was admitted to the Wrexham Maelor Hospital after becoming unwell. It was established that she had suffered an acute stroke and as she was on warfarin for a pre-existing condition , she was appropriately prescribed beriplex by way of treatment to reduce the risk of an extension of the bleed in her brain. Although this was prescribed at around 20.45 it was not administered until 07.35 the following morning despite it being a time critical treatment. By this time there had been an extension of the bleed with associated oedema and her condition had deteriorated significantly. Despite medical intervention and treatment in intensive care she was verified deceased at 18.30 on the 31st of January 2020
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.