Margaret Kelly
PFD Report
All Responded
Ref: 2023-0375
All 1 response received
· Deadline: 4 Dec 2023
Coroner's Concerns (AI summary)
Unsustainable pressure on emergency department staff, stemming from insufficient strategic planning and support, is causing treatment delays and raises concerns about patient safety and increased mortality.
View full coroner's concerns
Evidence was given at the inquest that when the deceased attended the emergency department it was at level 4 escalation (the highest level which they would escalate to), that this was far from unusual and that between March 2022 and the present day, the department would usually be operating between levels. 3 & 4. I am concerned that the pressure on clinicians and other staff is unsustainable and that delays in treatment will result in deaths. I do not consider that the operating practices within the department are a direct cause for concern (and as a result I do not require hearing the views of any clinicians in respect thereof), however I am concerned that insufficient or ineffective strategic planning and support is being undertaken and I would therefore wish to hear from those responsible at an executive/managerial level as to the steps which are being taken to reduce pressures within the department at Gian Clwyd.
Responses
Action Planned
Betsi Cadwaladr UHB acknowledges concerns about pressure on the Emergency Department at Ysbyty Glan Clwyd. They are undertaking a programme management approach organized into three phases to strengthen planning, leadership and governance across the Health Board and are working with operational and clinical teams. (AI summary)
Betsi Cadwaladr UHB acknowledges concerns about pressure on the Emergency Department at Ysbyty Glan Clwyd. They are undertaking a programme management approach organized into three phases to strengthen planning, leadership and governance across the Health Board and are working with operational and clinical teams. (AI summary)
View full response
Dear Mr Gittins,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Margaret Gertrude Kelly
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 09 October 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching upon the death of Mrs Margaret Kelly.
I would like to begin by offering my deepest condolences to the family and friends of Mrs Kelly for their loss.
In the Notice, you highlighted your concerns about unsustainable pressure on clinical staff at the Emergency Department at Ysbyty Glan Clwyd, and you wanted to know what action executive and senior management is taking to reduce those pressures.
The first part of our response addresses what is being done by the Central Integrated Health Community (IHC) to support the department. The Central IHC is the component of the Health Board responsible for planning, managing and improving integrated primary, community and secondary health services across Denbighshire and Conwy.
The Central IHC Leadership Team are working with our operational and clinical teams to ensure that we are providing the necessary support required in order to be able to provide our population with a service that supports a reduction in unscheduled care hospital attendances and ensure we improve the experience of our residents requiring urgent care.
Urgent & emergency care provision is one of the main priorities for the Central IHC and requires significant support and focus to deliver improvements. We have recognised that a programme management approach is required, and have established a dedicated project team to support the development and delivery of our improvement work related to urgent and emergency care. This additional capacity is vital in supporting operational teams to drive the programmes forward at pace and embed the change as we go.
Dyddiad / Date: 04 December 2023 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
Our Urgent and Emergency Care (UEC) Improvement Programme incorporates the delivery against our Special Measures priorities and the National Six Goals for Urgent and Emergency Care, taking a whole system approach which includes strengthening primary care, collaborating with our partners in local authority and WAST (the Welsh Ambulance Service Trust).
Our focus for the coming months (and beyond) is on supporting and bolstering our ability to deliver business as usual services, by reviewing how we deliver those services, and by moving existing resource to either support or work in a different way.
The following projects and work streams are underway to ensure we have a robust solution put in place to manage the emergency department pressures at Ysbyty Glan Clwyd:
The 8 Steps Project is aiming to improve each of the steps that patients take through their ED journey, creating efficiencies and therefore reducing the waiting time within the ED. Performance is being continuously monitored through a dashboard and to identify improvements to working practice. The 8 steps include:
1. Awaiting triage
2. Awaiting doctor
3. Awaiting ED plan
4. Awaiting ED decision
5. Awaiting specialty review
6. Awaiting specialty outcome
7. Senior decision to admit
8. Bed allocation
Daily focus on 8 steps to ED performance is undertaken in morning huddles with clinical, nursing and operational leads. The NHS Wales national improvement service, Improvement Cymru, are working with ED and site team from October to add challenge and support into the daily rhythm and flow
Work is underway to improve the YGC acute medical model. Operational teams are developing the model, rota and working patterns to support this. The objectives of the new model are to deliver timely patient care, provide senior decision-making support to the ED, and ensuring patients are cared for by the best medical specialty and in the right place.
Our Operational Management Team are working on two key areas around SDEC improvement: Improving the IT systems used by staff and using new telephony systems to support more referrals from GPs and WAST into the SDEC service.
Developing a more efficient board round system will expedite patients home in a timely manner, improving patient flow and relieving pressures upstream in the emergency department.
We are currently finalising plans to return the GP Out of Hours Service to the YGC. This is in line with Peer Review recommendations and will ensure co-located GP services to ED for nearly 70% of the week (6.30pm-8am Mon – Fri and all day Saturday and Sunday). We are currently working with operational leads to implement this provision before winter pressures this year. Patients presenting in YGC ED with primary care presentations during week day hours will be advised how they can access local primary care services (GP / Optometry / Community Pharmacy / Dental).
The IHC have re-established fortnightly strategic meetings with WAST to review demand and conveyances and actions that can be taken to reduce demand.
On 12 October 2023, IHC Directors presented current ambulance performance data at the monthly ED Governance Meeting to review actions required and identify the support needed to achieve zero tolerance of 4 Hour Ambulance Handover from 1st November 2023.
An ED rota review, including skill mix is scheduled for November as we have identified doctor shortages compared to attendances on Monday’s and Tuesday’s (two busiest days).
A test of a Monday to Friday 9am-5pm ‘see and treat’ model will also be undertaken during November for staff learning and to evaluate impact on non- admitted performance and de-compressing ED.
You will be aware of other work from our responses earlier in the year about ambulance handover delays, as part of the National Six Goals Programme, and I have not repeated that wider work here but I would wish to draw the link to that programme.
In relation to the main point of your Notice, regarding executive support, it is important for me to highlight the current position of the Health Board.
As you will know, the Health Board has been placed into Special Measures in February 2023 and since then, a new Interim Chair has been appointed, new Independent Members of the board are in place, and within the last few weeks, a new permanent Chief Executive has been appointed. A new interim Executive Director of Operations has also been appointed.
As part of our Special Measures programme, a number of Independent Reviews are underway into core aspects of the Health Board’s governance, planning and leadership. These reviews will help us shape how the Health Board will change in the future.
The Special Measures programme is organised into three phases – Stabilisation, Standardisation and Sustainability. We are currently at the Stabilisation phase and are
taking action to strengthen planning, leadership and governance across the Health Board. This work is being done against the requirement from Welsh Government to ensure financial savings are being delivered.
As an Executive Team, we are fully committed to supporting the ED through the Central IHC to develop and deliver its improvement plans, which are outlined above. We will scrutinise those plans and performance, and provide support.
The ED at Ysbyty Glan Clwyd continues to face significant pressure. You will be aware that Healthcare Inspectorate Wales designated it a Service Requiring Significant Improvement. We have supported the ED to develop and deliver considerable improvement plans in response to the three HIW inspections since February 2022, and during the summer of 2023 we supported a “mock inspection” (called a Quality Check) to provide an objective progress update. Our Executive Director of Nursing and Midwifery is overseeing the continuing actions arising from this process.
We will continue to support the ED and we expect a further HIW inspection in the near future, which will provide a further independent review of progress during which we hope to see it deescalated as a Service Requiring Significant Improvement.
I hope this letter sets out for you the actions we have taken to ensure the concerns you raised are being addressed.
We would be happy to meet with you further 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 Kelly for their loss.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Margaret Gertrude Kelly
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 09 October 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching upon the death of Mrs Margaret Kelly.
I would like to begin by offering my deepest condolences to the family and friends of Mrs Kelly for their loss.
In the Notice, you highlighted your concerns about unsustainable pressure on clinical staff at the Emergency Department at Ysbyty Glan Clwyd, and you wanted to know what action executive and senior management is taking to reduce those pressures.
The first part of our response addresses what is being done by the Central Integrated Health Community (IHC) to support the department. The Central IHC is the component of the Health Board responsible for planning, managing and improving integrated primary, community and secondary health services across Denbighshire and Conwy.
The Central IHC Leadership Team are working with our operational and clinical teams to ensure that we are providing the necessary support required in order to be able to provide our population with a service that supports a reduction in unscheduled care hospital attendances and ensure we improve the experience of our residents requiring urgent care.
Urgent & emergency care provision is one of the main priorities for the Central IHC and requires significant support and focus to deliver improvements. We have recognised that a programme management approach is required, and have established a dedicated project team to support the development and delivery of our improvement work related to urgent and emergency care. This additional capacity is vital in supporting operational teams to drive the programmes forward at pace and embed the change as we go.
Dyddiad / Date: 04 December 2023 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
Our Urgent and Emergency Care (UEC) Improvement Programme incorporates the delivery against our Special Measures priorities and the National Six Goals for Urgent and Emergency Care, taking a whole system approach which includes strengthening primary care, collaborating with our partners in local authority and WAST (the Welsh Ambulance Service Trust).
Our focus for the coming months (and beyond) is on supporting and bolstering our ability to deliver business as usual services, by reviewing how we deliver those services, and by moving existing resource to either support or work in a different way.
The following projects and work streams are underway to ensure we have a robust solution put in place to manage the emergency department pressures at Ysbyty Glan Clwyd:
The 8 Steps Project is aiming to improve each of the steps that patients take through their ED journey, creating efficiencies and therefore reducing the waiting time within the ED. Performance is being continuously monitored through a dashboard and to identify improvements to working practice. The 8 steps include:
1. Awaiting triage
2. Awaiting doctor
3. Awaiting ED plan
4. Awaiting ED decision
5. Awaiting specialty review
6. Awaiting specialty outcome
7. Senior decision to admit
8. Bed allocation
Daily focus on 8 steps to ED performance is undertaken in morning huddles with clinical, nursing and operational leads. The NHS Wales national improvement service, Improvement Cymru, are working with ED and site team from October to add challenge and support into the daily rhythm and flow
Work is underway to improve the YGC acute medical model. Operational teams are developing the model, rota and working patterns to support this. The objectives of the new model are to deliver timely patient care, provide senior decision-making support to the ED, and ensuring patients are cared for by the best medical specialty and in the right place.
Our Operational Management Team are working on two key areas around SDEC improvement: Improving the IT systems used by staff and using new telephony systems to support more referrals from GPs and WAST into the SDEC service.
Developing a more efficient board round system will expedite patients home in a timely manner, improving patient flow and relieving pressures upstream in the emergency department.
We are currently finalising plans to return the GP Out of Hours Service to the YGC. This is in line with Peer Review recommendations and will ensure co-located GP services to ED for nearly 70% of the week (6.30pm-8am Mon – Fri and all day Saturday and Sunday). We are currently working with operational leads to implement this provision before winter pressures this year. Patients presenting in YGC ED with primary care presentations during week day hours will be advised how they can access local primary care services (GP / Optometry / Community Pharmacy / Dental).
The IHC have re-established fortnightly strategic meetings with WAST to review demand and conveyances and actions that can be taken to reduce demand.
On 12 October 2023, IHC Directors presented current ambulance performance data at the monthly ED Governance Meeting to review actions required and identify the support needed to achieve zero tolerance of 4 Hour Ambulance Handover from 1st November 2023.
An ED rota review, including skill mix is scheduled for November as we have identified doctor shortages compared to attendances on Monday’s and Tuesday’s (two busiest days).
A test of a Monday to Friday 9am-5pm ‘see and treat’ model will also be undertaken during November for staff learning and to evaluate impact on non- admitted performance and de-compressing ED.
You will be aware of other work from our responses earlier in the year about ambulance handover delays, as part of the National Six Goals Programme, and I have not repeated that wider work here but I would wish to draw the link to that programme.
In relation to the main point of your Notice, regarding executive support, it is important for me to highlight the current position of the Health Board.
As you will know, the Health Board has been placed into Special Measures in February 2023 and since then, a new Interim Chair has been appointed, new Independent Members of the board are in place, and within the last few weeks, a new permanent Chief Executive has been appointed. A new interim Executive Director of Operations has also been appointed.
As part of our Special Measures programme, a number of Independent Reviews are underway into core aspects of the Health Board’s governance, planning and leadership. These reviews will help us shape how the Health Board will change in the future.
The Special Measures programme is organised into three phases – Stabilisation, Standardisation and Sustainability. We are currently at the Stabilisation phase and are
taking action to strengthen planning, leadership and governance across the Health Board. This work is being done against the requirement from Welsh Government to ensure financial savings are being delivered.
As an Executive Team, we are fully committed to supporting the ED through the Central IHC to develop and deliver its improvement plans, which are outlined above. We will scrutinise those plans and performance, and provide support.
The ED at Ysbyty Glan Clwyd continues to face significant pressure. You will be aware that Healthcare Inspectorate Wales designated it a Service Requiring Significant Improvement. We have supported the ED to develop and deliver considerable improvement plans in response to the three HIW inspections since February 2022, and during the summer of 2023 we supported a “mock inspection” (called a Quality Check) to provide an objective progress update. Our Executive Director of Nursing and Midwifery is overseeing the continuing actions arising from this process.
We will continue to support the ED and we expect a further HIW inspection in the near future, which will provide a further independent review of progress during which we hope to see it deescalated as a Service Requiring Significant Improvement.
I hope this letter sets out for you the actions we have taken to ensure the concerns you raised are being addressed.
We would be happy to meet with you further 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 Kelly for their loss.
Sent To
- Betsi Cadwaladr University Health Board
Response Status
Linked responses
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56-Day Deadline
4 Dec 2023
All responses received
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 11th of April 2022 an investigation was commenced into the death of Margaret Gertrude Kelly (DOB 21/4/39) who died at Gian Clwyd Hospital on the 31st of March 2022. The conclusion of the inquest on the 5th of October 2023 was by way of a narrative as detailed in paragraph 4 hereof with the cause of death being recorded as l(a) Multiorgan Failure (b) Intra-abdominal sepsis secondary to bowel perforation l(c) Abdominal wall hernia (operated) following hemicolectomy for adenocarcinoma of large bowel
Circumstances of the Death
On the 28th of March 2022, the deceased underwent an elective surgical hernia repair during which it is probable that her bowel became damaged. The following day she was in pain and attended the Emergency Department at Gian Clwyd Hospital as she had been unable to get an answer from the telephone number which she'd been given. She was not seen by a surgical doctor for several hours and by the following morning, the 30th of March, when her condition had deteriorated considerably, further emergency surgery was undertaken to repair the bowel perforation. As a result of there being several missed opportunities to optimize her care and treatment, Mrs Kelly no longer had the resilience to recover from this procedure and she died at Gian Clwyd Hospital on the afternoon of the 31st of March 2022. CORONER'S CONCERNS During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Evidence was given at the inquest that when the deceased attended the emergency department it was at level 4 escalation (the highest level which they would escalate to), that this was far from unusual and that between March 2022 and the present day, the department would usually be operating between levels. 3 & 4. I am concerned that the pressure on clinicians and other staff is unsustainable and that delays in treatment will result in deaths. I do not consider that the operating practices within the department are a direct cause for concern (and as a result I do not require hearing the views of any clinicians in respect thereof), however I am concerned that insufficient or ineffective strategic planning and support is being undertaken and I would therefore wish to hear from those responsible at an executive/managerial level as to the steps which are being taken to reduce pressures within the department at Gian Clwyd.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.