Glenys Button
PFD Report
Partially Responded
Ref: 2019-0192
Coroner's Concerns (AI summary)
Inefficient and outdated neurosurgical referral systems, relying on switchboards and bleeps, cause delays and miscommunications, with no backup for busy on-call doctors. Modern digital solutions are available but not utilized.
View full coroner's concerns
(1) There are a high number of referrals to the single rota'd on-call neurosurgical specialist registrar every day: The system for making and receiving the referrals is not fit for purpose, with inefficient delays, miscommunications and confusion occurring: The use of the UHW switchboard and bleeping the doctor is archaic, and does not utilise technology as it should. Further, if the on-call doctor is in surgery or dealing with an emergency, there is no back up doctor to field the referrals, which can often be time critical, (2) There is a similar situation with spinal specialists, where Cardiff has the experts and the outlying hospitals contact them for advice: A pro forma document has been designed which is filled in by local doctors and sent to a generic email address for the spinal team: The forma is considered and completed by the specialists and emailed back with answers. The only telephone call (to a direct number rather than the switchboard) involves the outlying hospital notifying the spinal team to expect an email referral: This system reduces the risk of delay and miscommunication, and provides a single, collaborative document for a patient' s notes. Could this be a better system to be used with neurosurgery referrals as a short-term measure? (3) There is a cutting-edge system used in Bristol, in Southmead Hospital, called wwwreferapatient org which uses modern technology to assist in referring patients between departments/hospitals. The website is self-explanatory: Could this be a better system to be used widely across the NHS in Wales in the longer term?
Responses
Action Planned
An e-referral system is being piloted, with an evaluation to follow three months after the pilot starts; however, networking issues have delayed the pilot's extension. In the interim, additional measures and email communication have been implemented to avoid delays in urgent referrals. (AI summary)
An e-referral system is being piloted, with an evaluation to follow three months after the pilot starts; however, networking issues have delayed the pilot's extension. In the interim, additional measures and email communication have been implemented to avoid delays in urgent referrals. (AI summary)
View full response
Dear Mrs Knight,
Re: Regulation 28 Report related to the death of Mrs Glenys Button
On the 10th June 2019 you issued this report to 5 separate Health Boards and requested a collaborative single response proposing a new system of referrals into Neurology at UHW. As the issues specifically relate to the Neurosurgical Service which is commissioned by the Welsh Health Specialised Services Committee (WHSSC) the WHSS team was asked to coordinate that response. In addition, Aneurin Bevan University Health Board (UHB), which did not receive the Regulation 28 Report but who also commission Neurosurgical Services from Cardiff and Vale (C&V UHB), have been included in this process.
A meeting was held on the 18th of July chaired by the Director of Nursing at C&VUHB which included management, clinical, patient safety team and IT representatives from C&VUHB as well as representatives from the patient’s Health Board of residence and the WHSS team. This group identified what they considered were the key issues and developed an action plan which was then considered by the Medical Directors of the six affected Health Boards. The summary below and the action plan reflects the input from the Medical Directors Group.
Welsh Health Specialised Services Committee Unit G1, Main Avenue Treforest Pontypridd CF37 5YL Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru Uned G1, Main Avenue, Trefforest Pontypridd CF37 5YL
Chair/Cadeirydd: Professor Vivienne Harpwood Managing Director of Specialised and Tertiary Services Commissioning/Rheolwr Gyfarwyddwr Comisiynu Gwasanaethau Arbenigol a Thrydyddol: Dr Sian Lewis
A number of key points have been agreed which inform the action plan:
1. An electronic referral system offers significant advantages in that it allows clearer and more detailed communication between referring and receiving clinicians however for very urgent cases telephone contact is still required. This is because it is not possible to provide 24 hour monitoring of email or web based referral systems.
2. Mobile phone signal in hospitals can be patchy and therefore bleeps are always required.
3. The C&VUHB IT team had already developed an in house e-referral systems which appears to have better functionality compared with the currently available commercial system.
The following action plan has been agreed for both paediatric and adult patients:
1. The current system for urgent and immediate care of patients with Emergency Neurosurgery needs will continue with the referral being made through the bleep system to the on call Neurosurgical Registrar. With effect from Monday 23rd September 2019 the referrer will be asked a question to gauge if the call is urgent or routine in nature. The urgency of the call will be communicated to the r Registrar via the bleep system which will enable them to prioritise urgent calls over less urgent tasks. If the Registrar is in theatre, there are arrangements in place to answer the bleep. Furthermore, if the Registrar cannot take the call, the referring team will be transferred back to switchboard for the on-call Neurosurgical Consultant to be contacted directly.
2. The on-call Neurosurgical Registrar will need to accept any emergency referrals and will ensure a clear plan is in place to manage the patient’s immediate care needs and to ensure effective communication with the referring team. Prior to the introduction of an e-referral system this will be followed up by an e–referral with a log of the call and the actions undertaken.
3. The new in house e-referral system will be piloted with Cwm Taf Morgannwg UHB starting at the beginning of August and a rigorous evaluation of the system built into the pilot from the outset. The evaluation will take place 3 months following the start of the pilot.
Following agreement of this action plan we have been told by C&V UHB that the pilot has identified networking issues between C&V and CTM UHB and that this
Welsh Health Specialised Services Committee Unit G1, Main Avenue Treforest Pontypridd CF37 5YL Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru Uned G1, Main Avenue, Trefforest Pontypridd CF37 5YL
Chair/Cadeirydd: Professor Vivienne Harpwood Managing Director of Specialised and Tertiary Services Commissioning/Rheolwr Gyfarwyddwr Comisiynu Gwasanaethau Arbenigol a Thrydyddol: Dr Sian Lewis
has prevented extension of the pilot study and these issues will need to be resolved before this can be rolled out further. The C&V UHB IT Development Team are working hard to resolve this issue as quickly as possible.
In conclusion, whilst we had hoped to be able to confirm a date for roll out of an e-referral system this is not possible, but we have put in additional measures to avoid delays in making urgent referrals as well as an interim arrangement using email to improve communication around the referral process. In addition the team at C&V UHB are working hard to address the IT issues as soon as possible. I will forward a copy of the most up to date referral pathway when I receive it from C&V UHB.
Please let me know if you require clarification or further information regarding these arrangements.
Re: Regulation 28 Report related to the death of Mrs Glenys Button
On the 10th June 2019 you issued this report to 5 separate Health Boards and requested a collaborative single response proposing a new system of referrals into Neurology at UHW. As the issues specifically relate to the Neurosurgical Service which is commissioned by the Welsh Health Specialised Services Committee (WHSSC) the WHSS team was asked to coordinate that response. In addition, Aneurin Bevan University Health Board (UHB), which did not receive the Regulation 28 Report but who also commission Neurosurgical Services from Cardiff and Vale (C&V UHB), have been included in this process.
A meeting was held on the 18th of July chaired by the Director of Nursing at C&VUHB which included management, clinical, patient safety team and IT representatives from C&VUHB as well as representatives from the patient’s Health Board of residence and the WHSS team. This group identified what they considered were the key issues and developed an action plan which was then considered by the Medical Directors of the six affected Health Boards. The summary below and the action plan reflects the input from the Medical Directors Group.
Welsh Health Specialised Services Committee Unit G1, Main Avenue Treforest Pontypridd CF37 5YL Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru Uned G1, Main Avenue, Trefforest Pontypridd CF37 5YL
Chair/Cadeirydd: Professor Vivienne Harpwood Managing Director of Specialised and Tertiary Services Commissioning/Rheolwr Gyfarwyddwr Comisiynu Gwasanaethau Arbenigol a Thrydyddol: Dr Sian Lewis
A number of key points have been agreed which inform the action plan:
1. An electronic referral system offers significant advantages in that it allows clearer and more detailed communication between referring and receiving clinicians however for very urgent cases telephone contact is still required. This is because it is not possible to provide 24 hour monitoring of email or web based referral systems.
2. Mobile phone signal in hospitals can be patchy and therefore bleeps are always required.
3. The C&VUHB IT team had already developed an in house e-referral systems which appears to have better functionality compared with the currently available commercial system.
The following action plan has been agreed for both paediatric and adult patients:
1. The current system for urgent and immediate care of patients with Emergency Neurosurgery needs will continue with the referral being made through the bleep system to the on call Neurosurgical Registrar. With effect from Monday 23rd September 2019 the referrer will be asked a question to gauge if the call is urgent or routine in nature. The urgency of the call will be communicated to the r Registrar via the bleep system which will enable them to prioritise urgent calls over less urgent tasks. If the Registrar is in theatre, there are arrangements in place to answer the bleep. Furthermore, if the Registrar cannot take the call, the referring team will be transferred back to switchboard for the on-call Neurosurgical Consultant to be contacted directly.
2. The on-call Neurosurgical Registrar will need to accept any emergency referrals and will ensure a clear plan is in place to manage the patient’s immediate care needs and to ensure effective communication with the referring team. Prior to the introduction of an e-referral system this will be followed up by an e–referral with a log of the call and the actions undertaken.
3. The new in house e-referral system will be piloted with Cwm Taf Morgannwg UHB starting at the beginning of August and a rigorous evaluation of the system built into the pilot from the outset. The evaluation will take place 3 months following the start of the pilot.
Following agreement of this action plan we have been told by C&V UHB that the pilot has identified networking issues between C&V and CTM UHB and that this
Welsh Health Specialised Services Committee Unit G1, Main Avenue Treforest Pontypridd CF37 5YL Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru Uned G1, Main Avenue, Trefforest Pontypridd CF37 5YL
Chair/Cadeirydd: Professor Vivienne Harpwood Managing Director of Specialised and Tertiary Services Commissioning/Rheolwr Gyfarwyddwr Comisiynu Gwasanaethau Arbenigol a Thrydyddol: Dr Sian Lewis
has prevented extension of the pilot study and these issues will need to be resolved before this can be rolled out further. The C&V UHB IT Development Team are working hard to resolve this issue as quickly as possible.
In conclusion, whilst we had hoped to be able to confirm a date for roll out of an e-referral system this is not possible, but we have put in additional measures to avoid delays in making urgent referrals as well as an interim arrangement using email to improve communication around the referral process. In addition the team at C&V UHB are working hard to address the IT issues as soon as possible. I will forward a copy of the most up to date referral pathway when I receive it from C&V UHB.
Please let me know if you require clarification or further information regarding these arrangements.
Sent To
- Cardiff and Vale University Health Board
- Cwm Taf Morgannwg University Health Board
- Hwyel Dda University Health Board
- Powys Teaching Health Board
- Swansea Bay University Health Board
- Welsh Assembly Government
Response Status
Linked responses
1 of 6
56-Day Deadline
18 Oct 2019
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 the 8th November 2018 an inquest was opened into the death of Glenys Button The investigation was concluded at a hearing on the 6th June 2019. The conclusion was that Mrs Button had suffered an accidental death, following a fall backwards onto a wooden floor at home: Bay from
Circumstances of the Death
Glenys Button was aged 78 on the Sth November 2018 when she died at the Royal Glamorgan Hospital. She had sustained a head injury involving a basal skull fracture and an unusual pneumocephalus and brain bleed, following a likely accidental backwards fall onto a wooden floor at her home address on 2nd November 2018. She had a number of co-morbidities including ischaemic heart disease, diabetes, osteoarthritis and chronic obstructive pulmonary disease: There is no neurosurgery ward at the Royal Glamorgan Hospital, therefore trauma doctors there (and similarly in other outlying units throughout South and West Wales) rely heavily upon emergency advice from the on-call neurosurgeons at the University Hospital of Wales in Cardiff as to the treatment and management of head and brain injury patients such as Mrs Button. It is the neurosurgeons who make the final decision as to whether to transfer the patient to the UHW for intervention. In this case, there were frustrating delays in contacting the on-call neurosurgery specialist registrar, there was confusion over whether Mrs Button was a suitable candidate for transfer to the unit in Cardiff for treatment, there was conflict over the discussion of her co-morbidities and there was inadequate written evidence of the various conversations. Following a deterioration in her condition, Mrs Button was firstly accepted, then rejected for transfer to Cardiff (mid-journey) and was ultimately managed conservatively on a trauma and orthopaedics ward at the RGH, where she succumbed to her devastating injuries:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths ad believe you and your organisation have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.