Robert Wright
PFD Report
All Responded
Ref: 2021-0374
Hospital Death (Clinical Procedures and medical management) related deaths
Wales prevention of future deaths reports (2019 onwards)
All 1 response received
· Deadline: 30 Dec 2021
Coroner's Concerns (AI summary)
Internal hospital referrals were paper-based and not promptly integrated into patient notes, leaving busy clinicians without immediate access to complete patient referral information.
View full coroner's concerns
In the circumstan~es it is my statutory duty to report to you. (1) While outpatient referrals from a GP would have been available to the surgeon via an IT system, his evidence was that referrals within the Hospital were made on paper (2) Those paper referrals were routinely not placed on the patient's notes until 2-3 days prior to the clinic, in this case many weeks after being made.
(3) In these circumstances there is clearly a risk that a clinician will not have available to them all ofthe relevant evidence regarding a patent's referrals and condition (4) A busy consultant clinician should not in any event be placed in the position ofhaving to look back through paper records to find a referral for a related condition which he had no reason to expect had been made.
(3) In these circumstances there is clearly a risk that a clinician will not have available to them all ofthe relevant evidence regarding a patent's referrals and condition (4) A busy consultant clinician should not in any event be placed in the position ofhaving to look back through paper records to find a referral for a related condition which he had no reason to expect had been made.
Responses
Action Planned
CTM UHB is exploring implementing electronic referrals and triaging, and is benchmarking practice with a neighbouring Health Board. A future project would be to consider an electronic patient pathway. (AI summary)
CTM UHB is exploring implementing electronic referrals and triaging, and is benchmarking practice with a neighbouring Health Board. A future project would be to consider an electronic patient pathway. (AI summary)
View full response
Dear Mr Regan Re: Regulation 28 - Robert Wright Thank you for your correspondence in relation to the above regulation 28 report, which details your areas of concern following the conclusion of the inquest, held on the 4th November 2021 into the sad death of Mr Robert Wright. Please be assured that the Health Board has taken this matter extremely seriously and action is being taken to address the matters highlighted during the inquest and those raised by yourself and the Regulation 28 report. We sincerely apologise to Mr Wright's family and would like to ensure that we have acted as directed by your findings. You asked us to take action to prevent future deaths and you believe that our organisation has the power to take such action. You asked us to take action on the following matters of concern. Croeso i chi gyfathrebu a'r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un iaith a ni fydd hyn yn arwain at oedi. You are welcome to correspond with the health board in Welsh or English. We will respond accordingly and this will not delay the response. Cyfeiriad Dychwelyd/Return Address; Bwrdd Iechyd Prifysgol Cwm Taf Morgannwg, Pencadlys, Pare Navigation, Abercynon, CF45 4SN Cwm Taf Morgannwg Un vers1ty Health Board, Headquarters, Nav1gat1on Park, Abercynon, CF45 4SN
8wrdd lechyd Prirysgol Cwm Taf Morgannwg yw enw gweithredol 8wrdd lechyd lleol Prifysgol Cwm Taf Morgannwg ICwm Taf Morgannwg University Health Soard 1s the operat,onal name of the Cwm Taf Morgannwg Urilvers,ty Local Health Board
While outpatient referrals from a GP would have been available to the Surgeon via an IT system, his evidence was that referrals within the hospital were made on paper: With regards to the first matter, referrals from General Practice are available on an IT system, however, these referrals are presented to the Consultant body for review on paper. The paper referrals are then triaged and patients are assigned to the appropriate clinics on an appropriate pathway. This is an area that we are looking at and with the appointment of our new Chief Digital Officer, , we are planning how we can possibly present the referrals to the Consultant body online and they would be triaged and vetted accordingly. We have also looked at benchmarking our practice within CTUMHB with a neighbouring Health Board where, currently, the referrals are reviewed and triaged online. Those paper referrals were routinely not placed on the patient's notes until 2-3 days prior to the clinic, in this case many weeks after being made: The clinic letters, with the triage outcome, are placed in the patient's notes and are available to the Consultant team prior to the patient's appointment in clinic. However, if the referral letter were not actually present in the patient's physical notes, the medical team would refer to the Welsh Clinical Portal where the referrals are evident. We wish to note that we have moved towards the electronic patient record and a large number of patient's records are no longer available in clinics in a paper format as we recognise that relying on paper is a risk. These notes are available to medical staff online and our staff have received training onto how to access information as required. In these circumstances there is clearly a risk that a clinician will not have available to them all of the relevant evidence regarding a patient's referral and condition: This is true and in this patient's case, he was already on a waiting list for a cholecystectomy. Had this information been available, this would have probably not changed the outcome. A busy consultant clinician should not in any event be placed in the position of having to look back through paper records to find a referral for a related condition which he had no reason to expect had been made: We agree with this matter of concern and the way forward is that all records will be available for all patients electronically. A future project would be to consider
an electronic patient pathway, which would digitally map out a patients pathway clearly and where a patient is seen, by when and what the action plan would be to have a holistic approach to patients care.
8wrdd lechyd Prirysgol Cwm Taf Morgannwg yw enw gweithredol 8wrdd lechyd lleol Prifysgol Cwm Taf Morgannwg ICwm Taf Morgannwg University Health Soard 1s the operat,onal name of the Cwm Taf Morgannwg Urilvers,ty Local Health Board
While outpatient referrals from a GP would have been available to the Surgeon via an IT system, his evidence was that referrals within the hospital were made on paper: With regards to the first matter, referrals from General Practice are available on an IT system, however, these referrals are presented to the Consultant body for review on paper. The paper referrals are then triaged and patients are assigned to the appropriate clinics on an appropriate pathway. This is an area that we are looking at and with the appointment of our new Chief Digital Officer, , we are planning how we can possibly present the referrals to the Consultant body online and they would be triaged and vetted accordingly. We have also looked at benchmarking our practice within CTUMHB with a neighbouring Health Board where, currently, the referrals are reviewed and triaged online. Those paper referrals were routinely not placed on the patient's notes until 2-3 days prior to the clinic, in this case many weeks after being made: The clinic letters, with the triage outcome, are placed in the patient's notes and are available to the Consultant team prior to the patient's appointment in clinic. However, if the referral letter were not actually present in the patient's physical notes, the medical team would refer to the Welsh Clinical Portal where the referrals are evident. We wish to note that we have moved towards the electronic patient record and a large number of patient's records are no longer available in clinics in a paper format as we recognise that relying on paper is a risk. These notes are available to medical staff online and our staff have received training onto how to access information as required. In these circumstances there is clearly a risk that a clinician will not have available to them all of the relevant evidence regarding a patient's referral and condition: This is true and in this patient's case, he was already on a waiting list for a cholecystectomy. Had this information been available, this would have probably not changed the outcome. A busy consultant clinician should not in any event be placed in the position of having to look back through paper records to find a referral for a related condition which he had no reason to expect had been made: We agree with this matter of concern and the way forward is that all records will be available for all patients electronically. A future project would be to consider
an electronic patient pathway, which would digitally map out a patients pathway clearly and where a patient is seen, by when and what the action plan would be to have a holistic approach to patients care.
Sent To
- Cwm Taf University Health Board
Response Status
Linked responses
1 of 1
56-Day Deadline
30 Dec 2021
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
A Coronial investigation was commenced on 291h March 2021 into the death of Robert Wright. The Investigation concluded at the end ofthe inquest which I conducted on 4th November 2021 . The conclusion was that Mr Wright died as the result ofnatural causes. The medical cause ofdeath was 1 (a) Necrotising cholecystitis; l(b) Gallstones
Circumstances of the Death
These were recorded as: Robert Wright, aged 80, suffered gallstones, which were first diagnosed in 2017. On 141h May 2019 he successfully underwent the removal ofa gallstone by ERCP, after which he was referred for consideration ofcholecystectomy. Following discharge, he developed biliary sepsis and underwent OGD, which identified suspected haematoma to the stomach wall. He was reviewed in clinic by the Consultant Surgeon on 2nd July 2019, who was unaware ofthe referral for consideration ofcholecystectomy. However, Mr Wright subsequently underwent CT and CTC investigation, which would been indicated in any event. On 26th July 2019 his condition deteriorated and he was taken to the Prince Charles Hospital where he died. Post mortem examination identified that this occurred as a result ofnecrotising cholecystitis caused by gallstones. During the investigation it became clear that the Consultant Surgeon who reviewed Mr Wright on 2m1July 2019 following Biopsy, CT scan and multi disciplinary discussion after OGD on 13th June 2019 was unaware that Mr Wright had been separately referred for surgical consideration of cholecystectomy following ERCP on l 5th May 2019 I would like to make clear that I found that there was absolutely no criticism to be made ofthat surgeon with respect to his lack ofawareness ofthis issue, and that in the case ofMr Wright I was satisfied that his treatment pathway would not have been altered in any event. However, it is a matter ofconcern that the surgeon assessing Mr Wright on 2nd July 2021 was not made aware ofthe related referral, a matter which in other circumstances may give rise to a risk ofdeath. CORONER'S CONCERNS During the course ofthe 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 circumstan~es it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) While outpatient referrals from a GP would have been available to the surgeon via an IT system, his evidence was that referrals within the Hospital were made on paper (2) Those paper referrals were routinely not placed on the patient's notes until 2-3 days prior to the clinic, in this case many weeks after being made. (3) In these circumstances there is clearly a risk that a clinician will not have available to them all ofthe relevant evidence regarding a patent's referrals and condition (4) A busy consultant clinician should not in any event be placed in the position ofhaving to look back through paper records to find a referral for a related condition which he had no reason to expect had been made.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.