Nancy Price
PFD Report
All Responded
Ref: 2023-0137
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 21 Jun 2023
Coroner's Concerns (AI summary)
The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning and preventing the timely implementation of safety improvements.
View full coroner's concerns
An investigation was commenced by the Health Board into the death of Nancy Carolyn Price, a significant time after her death and was completed only on 9 June 2022, some 17 months after her death. At Inquest it was identified that not all actions arising have been fully completed and the dates by when actions ought to have been completed (according to the investigation report) not adhered to. For example, the investigation report was due to be shared with vascular services to share learning by June 2022 (once approved) and yet the Report was only shared with vascular services in January 2023.
The actions arising from the investigation report are not always realistic. For example, one action was to identify any gaps in knowledge with regards to assessment and management of vascular emergencies, including recording of limb colour, sensation and movement, by the end of June 2022, approximately 3-4 weeks after the final report.
I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations.
I remain significantly concerned that the strategic management of internal Health Board investigations is lacking leading to investigations that are too slow, actions are not always realistic and, as a result, identification of areas for learning and training are not understood quickly enough, such that deaths will occur or will continue to occur into the future unless rapid action is taken.
The actions arising from the investigation report are not always realistic. For example, one action was to identify any gaps in knowledge with regards to assessment and management of vascular emergencies, including recording of limb colour, sensation and movement, by the end of June 2022, approximately 3-4 weeks after the final report.
I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations.
I remain significantly concerned that the strategic management of internal Health Board investigations is lacking leading to investigations that are too slow, actions are not always realistic and, as a result, identification of areas for learning and training are not understood quickly enough, such that deaths will occur or will continue to occur into the future unless rapid action is taken.
Responses
Action Planned
The Health Board is re-evaluating the incident process with a new procedure document to be developed by the end of August 2023, addressing overdue investigations with weekly meetings, and implementing training programmes after procedure approval. They have also commissioned a Patient Safety Improvement Programme. (AI summary)
The Health Board is re-evaluating the incident process with a new procedure document to be developed by the end of August 2023, addressing overdue investigations with weekly meetings, and implementing training programmes after procedure approval. They have also commissioned a Patient Safety Improvement Programme. (AI summary)
View full response
Dear Ms Robertson,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Nancy Carolyn Price
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 26 April 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Nancy Price.
I would like to begin by offering my deepest condolences to the family and friends of Mrs Price for their loss, and to apologise to them and to yourself for the failures that were identified during the inquest which led to your Notice.
In the Notice, you highlighted concerns regarding the Health Board’s strategic management of investigations and improvement actions.
I am aware that we have responded to a Notice form you on 09 May 2023 on the matter of investigations and actions, and we also have a further Notice to respond to along the same subject. I am also aware you met with our deputy director of nursing responsible for patient safety and the head of patient safety on 09 June 2023 to discuss investigations and actions.
For this response I would therefore wish to focus on reiterating the plans we have in place, as advised to you in other correspondence:
We are re-evaluating the incident process to identify how it can be streamlined and a new procedure document will be developed setting out roles and responsibilities. This will be complete by the end of August 2023. We are working to address those investigations currently overdue. A weekly improvement and scrutiny meeting, chaired by the Deputy Directors of Nursing, is held with clinical directors from our services to monitor, track and support the completion of serious incidents. We will be strengthening the performance and accountability process with our services to include overdue investigations.
Dyddiad / Date: 21 June 2023 Kate Robertson Assistant 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
In April 2022 we migrated to the new national “Once for Wales” Datix system for managing incidents. We are now utilising this system for the recording of actions following an investigation. All actions arising from a completed serious incident investigation will be added to this system on final approval of the investigation report by the Patient Safety Team, in addition to any that have already been identified from the rapid review or Rapid Learning Panel. Our divisionally-based Quality Governance Teams will support our services locally with understanding their open and overdue investigations and actions, and will support services to collate evidence of action completion. The Patient Safety Team have the role of monitoring performance and assuring the completion of actions. A new Organisational Learning Forum has recently been established. It is chaired by the Deputy Director of Nursing who leads on the patient safety agenda. This monthly meeting considers learning from across the organisation that arises from incidents, complaints, mortality reviews and other processes and is attended by clinical directors from all services with an aim of sharing learning. We have moved resources to strengthen our approach to learning, and a new Organisational Learning Manager has been appointed. We have also appointed a Director of Nursing for Quality Assurance and Learning who is supporting the Organisational Learning Forum mentioned above. We are strengthening the sharing of learning by developing a digital learning portal, a new lessons learned on a page template and a new learning bulletin. We will be strengthening the assurance of learning by developing a new Quality Assurance Framework and a strengthened quality assurance team. Over the next few months, our Organisational Learning Manager is engaging with staff across the organisation to understand how we can better support learning. This will develop into a new approach to learning with a framework and toolkit, which will include the actions already mentioned. We are looking at best practice both within NHS Wales, across the border and in the private sector. We are hopeful to be getting national support from the NHS Wales Executive to co-pilot an innovative new learning model for the NHS in Wales. We are reviewing our training for those undertaking investigations and writing action plans and will launch new training programmes following approval of the new procedure outlined above. To support the delivery of safety and quality improvements across the organisation, we have commissioned a Patient Safety Improvement Programme. This patient safety initiative aims to support a culture of safety, continuous learning and sustainable improvement across the healthcare system. The programme will focus on the reduction of avoidable harm through safe and reliable care processes.
As we wrote in our response to your earlier Notice, you will be aware the Health Board has been placed into Special Measures and one domain of this is clinical governance, patient safety and experience and a second domain is learning from incidents.
The actions we have detailed above form part of our plans for Special Measures, particularly the review of our incident process and ensuring the timely completion of investigations and the timely completion of action plans with evidence. This work is one of our immediate priorities for the first six months of Special Measures.
As part of this Special Measures process we are awaiting an expert independent review into Patient Safety, and a further expert independent review into Clinical Governance will be commencing shortly. We will using the findings of these reviews to help identify and make further improvements to our processes.
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 Price for their loss and I reiterate my sincere apologies to them and to you for the concerns rightly identified at the inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Nancy Carolyn Price
I write in response to the Regulation 28 Report to Prevent Future Deaths dated 26 April 2023, issued by yourself to Betsi Cadwaladr University Health Board, following the inquest touching the death of Nancy Price.
I would like to begin by offering my deepest condolences to the family and friends of Mrs Price for their loss, and to apologise to them and to yourself for the failures that were identified during the inquest which led to your Notice.
In the Notice, you highlighted concerns regarding the Health Board’s strategic management of investigations and improvement actions.
I am aware that we have responded to a Notice form you on 09 May 2023 on the matter of investigations and actions, and we also have a further Notice to respond to along the same subject. I am also aware you met with our deputy director of nursing responsible for patient safety and the head of patient safety on 09 June 2023 to discuss investigations and actions.
For this response I would therefore wish to focus on reiterating the plans we have in place, as advised to you in other correspondence:
We are re-evaluating the incident process to identify how it can be streamlined and a new procedure document will be developed setting out roles and responsibilities. This will be complete by the end of August 2023. We are working to address those investigations currently overdue. A weekly improvement and scrutiny meeting, chaired by the Deputy Directors of Nursing, is held with clinical directors from our services to monitor, track and support the completion of serious incidents. We will be strengthening the performance and accountability process with our services to include overdue investigations.
Dyddiad / Date: 21 June 2023 Kate Robertson Assistant 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
In April 2022 we migrated to the new national “Once for Wales” Datix system for managing incidents. We are now utilising this system for the recording of actions following an investigation. All actions arising from a completed serious incident investigation will be added to this system on final approval of the investigation report by the Patient Safety Team, in addition to any that have already been identified from the rapid review or Rapid Learning Panel. Our divisionally-based Quality Governance Teams will support our services locally with understanding their open and overdue investigations and actions, and will support services to collate evidence of action completion. The Patient Safety Team have the role of monitoring performance and assuring the completion of actions. A new Organisational Learning Forum has recently been established. It is chaired by the Deputy Director of Nursing who leads on the patient safety agenda. This monthly meeting considers learning from across the organisation that arises from incidents, complaints, mortality reviews and other processes and is attended by clinical directors from all services with an aim of sharing learning. We have moved resources to strengthen our approach to learning, and a new Organisational Learning Manager has been appointed. We have also appointed a Director of Nursing for Quality Assurance and Learning who is supporting the Organisational Learning Forum mentioned above. We are strengthening the sharing of learning by developing a digital learning portal, a new lessons learned on a page template and a new learning bulletin. We will be strengthening the assurance of learning by developing a new Quality Assurance Framework and a strengthened quality assurance team. Over the next few months, our Organisational Learning Manager is engaging with staff across the organisation to understand how we can better support learning. This will develop into a new approach to learning with a framework and toolkit, which will include the actions already mentioned. We are looking at best practice both within NHS Wales, across the border and in the private sector. We are hopeful to be getting national support from the NHS Wales Executive to co-pilot an innovative new learning model for the NHS in Wales. We are reviewing our training for those undertaking investigations and writing action plans and will launch new training programmes following approval of the new procedure outlined above. To support the delivery of safety and quality improvements across the organisation, we have commissioned a Patient Safety Improvement Programme. This patient safety initiative aims to support a culture of safety, continuous learning and sustainable improvement across the healthcare system. The programme will focus on the reduction of avoidable harm through safe and reliable care processes.
As we wrote in our response to your earlier Notice, you will be aware the Health Board has been placed into Special Measures and one domain of this is clinical governance, patient safety and experience and a second domain is learning from incidents.
The actions we have detailed above form part of our plans for Special Measures, particularly the review of our incident process and ensuring the timely completion of investigations and the timely completion of action plans with evidence. This work is one of our immediate priorities for the first six months of Special Measures.
As part of this Special Measures process we are awaiting an expert independent review into Patient Safety, and a further expert independent review into Clinical Governance will be commencing shortly. We will using the findings of these reviews to help identify and make further improvements to our processes.
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 Price for their loss and I reiterate my sincere apologies to them and to you for the concerns rightly identified at the inquest.
Sent To
- Betsi Cadwaladr University Local Health Board
Response Status
Linked responses
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56-Day Deadline
21 Jun 2023
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
Report Sections
Investigation and Inquest
On 11 January 2021 an investigation was commenced into the death of Carolyn Nancy Price (DOB 3/6/1958) who died on 1 January 2021. The investigation concluded at the end of the inquest on 25 April 2023. The conclusion of the inquest was a narrative conclusion as follows : Nancy Carolyn Price died on 1 January 2021 at Ysbyty Glan Clwyd. There was a delay in assessing her and transferring her from Ysbyty Maelor to Ysbyty Glan Clwyd to the extent that there were missed opportunities for her to undergo timely and possible life saving surgery.
Circumstances of the Death
The circumstances of the death are as follows : Nancy Carolyn Price, aged 62 at the time of her death, presented to the Emergency Department of Wrexham Maelor Hospital on 30 December 2020 via ambulance which had arrived at her home at 16:37. She had sudden onset of movement and sensation in both lower limbs since midday. She was eventually seen by a medic, at approximately 9.45pm, when limb ischaemia was diagnosed. In consultation with the on call vascular consultant at Ysbyty Glan Clwyd, where vascular services are centralised for the Health Board, urgent CT angiogram was advised, IV heparin and pain relief, and also urgent ambulance transfer to Ysbyty Glan Clwyd. Nancy Price arrived many hours later, at approximately 3am and required rehydrating prior to the surgery. The surgery was commenced at approximately 05:55. Following surgery she developed multi organ failure and died on 1 January 2021.
Inquest Conclusion
Nancy Carolyn Price died on 1 January 2021 at Ysbyty Glan Clwyd. There was a delay in assessing her and transferring her from Ysbyty Maelor to Ysbyty Glan Clwyd to the extent that there were missed opportunities for her to undergo timely and possible life saving surgery.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.