Trevor Reynolds
PFD Report
All Responded
Ref: 2022-0132
All 1 response received
· Deadline: 1 Jul 2022
Response Status
Responses
1 of 1
56-Day Deadline
1 Jul 2022
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
1. Although it was identified quickly that existing working practices (whereby an irregular scan report had been placed on the desk of a clinician by a secretary and due to the absence of the clinician this report had not been seen and acted upon in a timely manner,) the health board did not fully implement a new Standard Operating Procedure, which was introduced to address this issue, until December 2021, seven months after the death of Mr Reynolds.
2. Furthermore an acknowledgement of the existence of the new SOP by Oncology and Haematology Secretaries was not completed until the 22nd of February 2022.
3. Finally at the time of the inquest, eleven days prior to the anniversary of Mr Reynolds’ death the health board had not completed an audit process to ensure that the changes which had been introduced were being complied with and were therefore effective.
4. I am concerned that the length of time which it takes to implement changes and to ensure that new safe working practices are introduced and adopted by staff, results in the health board allowing known risks to patients to continue and therefore presents a risk to life.
2. Furthermore an acknowledgement of the existence of the new SOP by Oncology and Haematology Secretaries was not completed until the 22nd of February 2022.
3. Finally at the time of the inquest, eleven days prior to the anniversary of Mr Reynolds’ death the health board had not completed an audit process to ensure that the changes which had been introduced were being complied with and were therefore effective.
4. I am concerned that the length of time which it takes to implement changes and to ensure that new safe working practices are introduced and adopted by staff, results in the health board allowing known risks to patients to continue and therefore presents a risk to life.
Responses
Betsi Cadwaladr University Health Board has made all relevant clinicians and secretaries aware of the Standard Operating Procedure (SOP) for escalating urgent radiology results, adding it to induction checklists and meeting agendas. Completed audits confirm the procedure is now embedded as normal working practice, and ongoing monthly audits will continue.
AI summary
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Dear Mr Gittins,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Trevor Reynolds
I write in response to the Regulation 28 Report to Prevent of Future Deaths dated 06 May 2022, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Trevor Reynolds.
I would like to begin by offering my deepest condolences to the family and friends of Mr Reynolds, and I apologise for the concerns identified at the inquest that have given rise to your notice.
Firstly, I would like to address the concerns regarding the length of time taken to make changes and how we ensure new working practices are adopted by staff.
Within the Cancer Division, all clinicians and secretaries in oncology and haematology have been made aware of the Standard Operating Procedure (SOP) for the Escalation of Urgent Radiology Results Containing Unexpected Findings. The SOP has been added to the Induction Checklist for all new starters who commence within the Cancer Division and it has been added as a regular agenda item on all secretarial meetings. The learning from this matter has been shared with other health board services.
The Cancer Division have completed two audits of compliance with the SOP (27 May 2022 and 21 June 2022) since the notice was issued. The first audit did identify areas of non-compliance with the SOP, however following further training and reinforcement, the second audit shows the change in procedure has become embedded as normal working practice and there is evidence within the medical notes that action has been taken in all cases. Ongoing monthly audits of the process will be completed and the findings will be reported formally to the Cancer Services Governance Meeting. The SOP has been updated following the results of the audits so far and will be regularly reviewed along with future audit findings.
Ein cyf / Our ref: JW/MJ/DL/3127 Eich cyf / Your ref: :
Gofynnwch am / Ask for:
E-bost / Email:
Dyddiad / Date: 1st July 2022 Mr John Gittins Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN
In respect of diagnostic results and follow up, I am aware this is an issue that you have raised previously, and despite the introduction of written procedures, this does remain a concern. We accept that a resilient solution is needed.
Last year, the Health Board established a Results Management Project with the aim of eliminating printed or hard copy results and integrating reporting to our digital clinical system known as the Welsh Clinical Portal. This work has been developed in collaboration with Digital Health and Care Wales, the national NHS Wales organisation who manage many of our digital clinical systems. I am pleased to advise this development work has been completed and the new electronic functionality has been tested and is ready for roll-out.
Following your notice, our senior medical and quality teams have discussed rapid rollout of this electronic solution. Our intention is to implement this new digital solution over the summer with our respiratory speciality as an early adopter service, with the learning from that implementation informing full roll-out across the health board by the end of the year. A formal evaluation covering the implementation will then take place in January/February
2023.
We have reviewed the case of Mr Reynolds in detail following the inquest and note that the investigation report was completed within the required time and the action plan stated reasonable deadlines; however, these deadlines where not achieved and as you have identified the delivery of actions was unacceptably delayed.
To improve internal oversight, our bi-monthly Patient Safety Report (from June 2022 onwards) will provide a breakdown of all overdue actions by division and service. This report is presented to our Executive-led quality group and ultimately our Board quality committee. This will ensure the visibility of action delivery performance and enable divisions to be held to account for their performance through these governance forums and through their Accountability Review Meetings.
Additionally, we will shortly be undertaking an organisational change process for our quality function and this will provide greater clarity and expectation for quality staff based locally within divisions. They will operate in a business partner model, providing local support at directorate and divisional level with a key part of their role supporting, challenging and reporting on action delivery. We are currently finalising the proposal for this function with a view to the changes taking place over the coming months. A workshop for staff has been arranged for 14 July 2022. This work links to our wider organisational development strategy called Stronger Together, which is also implementing a new operating structure for divisions and new leadership roles with clearly defined responsibilities (this includes delivery of improvement work). This new divisional model is planned for implementation during late summer 2022. I have provided broad delivery dates - the exact dates for this work will be finalised shortly following conclusion of certain workforce change processes.
Additionally, we are currently in the process of reviewing our approach to clinical audit. We will closer align our audit programme with the risks that we have identified through issues such as serious incident reporting and inquest matters. We have also recently procured a new electronic audit system and we are in the process of rolling this out. This system will improve the digital completion of audits and the reporting of assurances.
Taken together, the improved clarity of new leadership roles, improved local support for quality, improved visibility of performance reporting, and a strengthened approach to clinical audit, will allow us to strengthen the timely delivery of actions and the visibility of performance across the organisation.
I hope my letter offers you assurance that we have worked to address the concerns you identified.
One again, please may I offer my condolences to the loved ones of Mr Reynolds.
Should you require any further information or evidence of the actions outlined above please contact either myself or Matthew Joyes, Associate Director of Quality.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Trevor Reynolds
I write in response to the Regulation 28 Report to Prevent of Future Deaths dated 06 May 2022, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Trevor Reynolds.
I would like to begin by offering my deepest condolences to the family and friends of Mr Reynolds, and I apologise for the concerns identified at the inquest that have given rise to your notice.
Firstly, I would like to address the concerns regarding the length of time taken to make changes and how we ensure new working practices are adopted by staff.
Within the Cancer Division, all clinicians and secretaries in oncology and haematology have been made aware of the Standard Operating Procedure (SOP) for the Escalation of Urgent Radiology Results Containing Unexpected Findings. The SOP has been added to the Induction Checklist for all new starters who commence within the Cancer Division and it has been added as a regular agenda item on all secretarial meetings. The learning from this matter has been shared with other health board services.
The Cancer Division have completed two audits of compliance with the SOP (27 May 2022 and 21 June 2022) since the notice was issued. The first audit did identify areas of non-compliance with the SOP, however following further training and reinforcement, the second audit shows the change in procedure has become embedded as normal working practice and there is evidence within the medical notes that action has been taken in all cases. Ongoing monthly audits of the process will be completed and the findings will be reported formally to the Cancer Services Governance Meeting. The SOP has been updated following the results of the audits so far and will be regularly reviewed along with future audit findings.
Ein cyf / Our ref: JW/MJ/DL/3127 Eich cyf / Your ref: :
Gofynnwch am / Ask for:
E-bost / Email:
Dyddiad / Date: 1st July 2022 Mr John Gittins Senior Coroner North Wales (East and Central) Coroner's Office County Hall Wynnstay Road Ruthin LL15 1YN
In respect of diagnostic results and follow up, I am aware this is an issue that you have raised previously, and despite the introduction of written procedures, this does remain a concern. We accept that a resilient solution is needed.
Last year, the Health Board established a Results Management Project with the aim of eliminating printed or hard copy results and integrating reporting to our digital clinical system known as the Welsh Clinical Portal. This work has been developed in collaboration with Digital Health and Care Wales, the national NHS Wales organisation who manage many of our digital clinical systems. I am pleased to advise this development work has been completed and the new electronic functionality has been tested and is ready for roll-out.
Following your notice, our senior medical and quality teams have discussed rapid rollout of this electronic solution. Our intention is to implement this new digital solution over the summer with our respiratory speciality as an early adopter service, with the learning from that implementation informing full roll-out across the health board by the end of the year. A formal evaluation covering the implementation will then take place in January/February
2023.
We have reviewed the case of Mr Reynolds in detail following the inquest and note that the investigation report was completed within the required time and the action plan stated reasonable deadlines; however, these deadlines where not achieved and as you have identified the delivery of actions was unacceptably delayed.
To improve internal oversight, our bi-monthly Patient Safety Report (from June 2022 onwards) will provide a breakdown of all overdue actions by division and service. This report is presented to our Executive-led quality group and ultimately our Board quality committee. This will ensure the visibility of action delivery performance and enable divisions to be held to account for their performance through these governance forums and through their Accountability Review Meetings.
Additionally, we will shortly be undertaking an organisational change process for our quality function and this will provide greater clarity and expectation for quality staff based locally within divisions. They will operate in a business partner model, providing local support at directorate and divisional level with a key part of their role supporting, challenging and reporting on action delivery. We are currently finalising the proposal for this function with a view to the changes taking place over the coming months. A workshop for staff has been arranged for 14 July 2022. This work links to our wider organisational development strategy called Stronger Together, which is also implementing a new operating structure for divisions and new leadership roles with clearly defined responsibilities (this includes delivery of improvement work). This new divisional model is planned for implementation during late summer 2022. I have provided broad delivery dates - the exact dates for this work will be finalised shortly following conclusion of certain workforce change processes.
Additionally, we are currently in the process of reviewing our approach to clinical audit. We will closer align our audit programme with the risks that we have identified through issues such as serious incident reporting and inquest matters. We have also recently procured a new electronic audit system and we are in the process of rolling this out. This system will improve the digital completion of audits and the reporting of assurances.
Taken together, the improved clarity of new leadership roles, improved local support for quality, improved visibility of performance reporting, and a strengthened approach to clinical audit, will allow us to strengthen the timely delivery of actions and the visibility of performance across the organisation.
I hope my letter offers you assurance that we have worked to address the concerns you identified.
One again, please may I offer my condolences to the loved ones of Mr Reynolds.
Should you require any further information or evidence of the actions outlined above please contact either myself or Matthew Joyes, Associate Director of Quality.
Report Sections
Investigation and Inquest
On the 25th of May 2021 I commenced an investigation into the death of Trevor Reynolds (DOB 14.4.42 DOD 15.5.21). The investigation concluded at the end of the inquest on the 4th of May 2022. The conclusion of the inquest was a narrative in the following terms : “On the 3rd of May 2021, Mr Trevor Reynolds had a CT scan at Glan Clwyd Hospital, the purpose of which was to establish the effectiveness of treatment which he had been having for cancer of the oesophagus. On the 6th of May this was reported by a radiologist as incidentally revealing a clot on the lungs, a result which needed to be brought to the immediate attention of the referring clinician so that remedial treatment could be started. For reasons associated with working practices at that time the result of this scan was not acted upon until it was identified by Mr Reynold’s GP on the 10th of May and he was immediately admitted to hospital where treatment was commenced. Despite appropriate treatment being undertaken over the course of the next few days, Mr Reynolds passed away at Glan Clwyd Hospital on the 15th of May 2021 with a subsequent examination establishing that he had died as a result of both the pulmonary emboli and a pneumonia. The evidence indicated that had treatment for the clot began sooner there would have been a better prospect of it being successful and further that the treatment for his cancer had been effective. On the balance of probabilities therefore it is likely that Mr Reynolds would not have died on the 15th of May 2021 if the result of his scan had been acted upon when reported by the radiologist on the 6th of May.” The Cause of Death being recorded as 1(a) Pneumonia and Pulmonary Emboli due to Deep Vein Thrombosis 2.Emphysema of the Lung and Carcinoma of the Oesophagus (Treated)
Circumstances of the Death
The circumstances of the death are as detailed in the narrative conclusion referred to above
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.