Dear Ms Saunders Re: Maria Christine Shafighian Thank you for your letter following the conclusion of the inquest into Ms Shafighians death and the request to outline the actions taken to comply with regulation 28 Prevention of Future Deaths. To respond to internal processes for managing Ear,Nose,Throat(ENT) referrals from other specialties. The current process for internal referrals is that a referral letter may be sent directly to the ENT department, where it will be seen and triaged by a consultant, then forwarded to the Central Registration department, where it is loaded onto the Clinical Workstation. These referrals are then sent electronically to the Consultants in ENT for triage. The triage involves review and prioritisation of the referrals as Urgent Suspected Cancer, Urgent and Routine. Following triage, the patient’s details are updated on Clinical Workstation. Patients are then placed on the waiting list, and an acknowledgement letter is sent to the patient. For patients listed as an Urgent Suspected Cancer (USC) there is a tracking system that monitors them through the patient pathway until completion or commencement of treatment. In the case of Ms Shafighian, the patient was seen and assessed in ENT and was then discharged from ENT to the Speech and Language therapy (SALT) service. During a video consultation, the SALT therapist noted that Ms Shafighian was struggling to swallow, so a referral was sent to ENT for an urgent opinion. Pencadlys Headquarters Ysbyty Sant Cadog St Cadoc’s Hospital Ffordd Y Lodj Lodge Road Caerllion Caerleon Casnewydd Newport De Cymru NP18 3XQ South Wales NP18 3XQ Ffôn: 01633 436700 Tel No: 01633 436700 Bwrdd Iechyd Prifysgol Aneurin Bevan yw enw gweithredol Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan Aneurin Bevan University Health Board is the operational name of Aneurin Bevan University Local Health Board

This referral letter typed by SALT is uploaded onto the MedSecs system, and the GP is sent a copy. The letter was then printed and sent to the ENT department manually (as outlined in the report). This referral letter would then be seen by one of the ENT Consultants, triaged and then sent to Central Registration for them to upload onto the Clinical Workstation system. At this point, an acknowledgement would be sent to the patient informing them of this waiting list entry. In order to improve the system, speed up the process, and provide a more robust audit trail of referral demands, it has been discussed and agreed that internal referrals to the ENT department need to be sent straight to the Central Registration department for them to take action and upload the information on the referral, and send this electronically to the ENT consultants for triage. This would mirror the GP process. In addition, Head and Neck Cancer Lead, has communicated to the Head and Neck MDTs and supporting services that for any urgent clinical developments requiring an ENT opinion, these should also be e-mailed. The Directorate is also in the process of developing a generic internal electronic referral form that would need to be completed for any patients needing ENT input or an opinion. This would remove the need for paper letters or referrals to be sent, speed up the process, and provide an audit trail of receipt and action on the system. The provision of an internal e-referral process will speed up the process, reduce the risk of referrals being delayed or lost in the system, and provide an audit. I hope this response outlines the current process and actions that the Health Board has taken and is in the process of taking. If you have any further questions, please contact Directorate Manager Head and Neck Services on who would be happy to discuss this with you.