In the circumstances it is my statutory duty t0 report t0 you: [BRIEF SUMMARY OF MATTERS OF CONCERN] In the event that a patient at Prince Charles Hospital is deemed suitable for PCI there is currently no formal back up plan in place, to enable the PCI to proceed, should UHW in Cardiff or Morriston Hospital in Swansea be unable t0 accept that patient:
2) In such circumstances, a patient meeting the criteria for PCI is unable to undergo that procedure, increasing the risk of his/her death, until there is such capacity for that patient to be admitted to UHW or Morriston Hospitals for PCI:
3) As per the evidence OL given at inquest, an agreed short term pathway needs t0 be put in place to access adult critical care beds outside Wales and a bed management pathway put in place_
4) There is currently no agreed pathway for an unconscious STEMI patient requiring PCI in tertiary services as there is currently for conscious patients with STEMI: Although in the case of Dr Hassan transfer to another hospital for a rescue PCI was not clinically indicated, that may not necessarily be the case in the future, particularly, in a patient who has had a short period of unconsciousness and a PCI is clinically indicated_
5) In similar circumslances as pertained on the evening prior t0 the morning of Dr Hassan's death such a patient (as described in 4)) maybe deprived the opportunity of undergoing rescue PCI due to lack of capacity at either UHW in Cardiff or Morriston in Swansea, ActION SHOULD BE TAKEN In my opinion action should be taken t0 prevent future deaths and believe you and your organisation have the power t0 take such action. In particular, formulating and implementing & formal backup plan in the event that both UHW and Morriston Hospitals are unable t0 accept a patient for PCI and by the creation and implementation of an agreed pathway for the unconscious STEMI patient requiring PCI in tertiary services_ YOUR RESPONSE You are under a to respond to this report within 56 days of the date of this report, namely by 1st November 2016. I, the coroner, may extend the period Your response must contain details of action laken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES ad PUBLICATION have sent & copy of my report to the Chief Coroner, Cardiff & Vale Medical Director, ABMU Medical Director, Cwm Taff Medical Director, Welsh Health Specialised Services Committee, Minister for Health & Social Services and the family who may find it useful or of interest; am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest, You may make representations t0 me; the coroner,at the time of your response, about the release or the publication of your response by the Chief Coroner_ 5" September 2016 SIGNED: Graeme Hughes HM Asslstant Coroner duty