Pamela Conway
PFD Report
All Responded
Ref: 2016-0309
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
All 2 responses received
· Deadline: 21 Oct 2016
Coroner's Concerns (AI summary)
Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.
View full coroner's concerns
busy delay part
a5 follows That notwithstanding changes which have been made by both BCuHB and WAST , there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues_ Evidence at the inquest indicated that the problem of "patient flow" within the Maelor Hospital continues to result in delays within the Emergency Department and it is of considerable concern to me that such problems have been the subject of previous regulation 28 reports and are also within the scope of a number of ongoing inquests.
a5 follows That notwithstanding changes which have been made by both BCuHB and WAST , there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls as a result of which the risk of future deaths continues_ Evidence at the inquest indicated that the problem of "patient flow" within the Maelor Hospital continues to result in delays within the Emergency Department and it is of considerable concern to me that such problems have been the subject of previous regulation 28 reports and are also within the scope of a number of ongoing inquests.
Responses
Action Taken
The Welsh Ambulance Service NHS Trust has made progress against key actions identified in an attached action plan, with the most significant impact from the Welsh Health Circular regarding hospital handover guidance. Lessons learned from the case are being monitored through a Task and Finish Group. (AI summary)
The Welsh Ambulance Service NHS Trust has made progress against key actions identified in an attached action plan, with the most significant impact from the Welsh Health Circular regarding hospital handover guidance. Lessons learned from the case are being monitored through a Task and Finish Group. (AI summary)
View full response
Dear May Mick LbcWr ( 1 Fotl 0549169
Please do not hesitate to contact me if you have any questions with regards to the action plan On a more general note look forward to meeting you and colleagues in your coronial area to discuss areas of concerns to us all as we discussed in the Summer
Please do not hesitate to contact me if you have any questions with regards to the action plan On a more general note look forward to meeting you and colleagues in your coronial area to discuss areas of concerns to us all as we discussed in the Summer
Action Planned
The University Health Board is scrutinizing two working action plans relating to the case, which will be monitored by the Quality and Safety Group. (AI summary)
The University Health Board is scrutinizing two working action plans relating to the case, which will be monitored by the Quality and Safety Group. (AI summary)
View full response
Dear Mr Olitlns Re: Rogulation 20 loftor in recpect of Pamela Conwy Further to your Regulation 28 notifications to the Health Board following the inquest 0f Pamela Conwy: The Health Board has coneidered your concerne in relation to the following issues outlined in the two notifications: Elret Regulation 28 Notiicztion Pert 1 Thet not Withstanding chenger wiich have been mede by both BCUHB end WAST, there remein Wnolly unacceptabla delaye with paliente being kept welting for long periode in embulences and ambulance resourcee consequances being unavailable for allocation to Oiner calls &8 & rasult of wnich the risk of future deaths continuas Part 2 Evidence at the inquest indicated ihat the problem of patient fiow in tne Maelor result In patlent dslsye within the Emergency Deparment and it is of considerable concem t0 ma dhat euch probleme have been ihe subjeot of previous regulation 28 reports and ar also within the scope of & number of ongoing inquesis Second Requlatinn 28 Notiiicaion Pah 1 Evdence at ihe inquest indlcated thet dlscuceiong ware faking place between dllierent deparirnente wthln BCUHE with & view io agreeing & proiocol to establish an approprlate care pathway for patlenta pragentlng {0 Ine hospltel with an Infecied prosinesie, howaver nothing had been finalised regarding tha seme: Part 2 Furtherore evidence Indlcated that although it was always Intended {hat antibiotics would be administered once Ihe patient's khee had been aspirated, {here Was & of almost twvo houre between this procedure &nd Ihe adminiciration of antibiotics (@ which wrs expleined by beirig due d0 tnomal hospital proceduras Cyielicd Gahebleath ar gyiar y Cadelryud &ttr Prlf Welthreciz / Coreapondenc? eddtese for Chelrman end Chlet Exccutea: Suydciat @welinrcawyr Executives' Oitice , Yebyty Gwynedd, Fenrhoegamedd Dangor; Gwynedd LL67 ZFW Gwofan: Wvw-pbc cymru nhsuk Wob: unwbcu,walcz nheuk WR delay delay
GIG Bwrdd lechyd Prifysgol CYMEU Betsi Cadwaladr NHS University Health Boerd Wales Therefore please find enclosed two working action plans relating to this cage. The action plans will be scrutinized by the Assistant Director or Nursing as well as the Hospital Medical Director and will be monifored by the at the Quality and Safety Group to ensure timely progress. Yourc sincerely Mr Evan Mooro Exocutive Mlodical Director Enc
GIG Bwrdd lechyd Prifysgol CYMEU Betsi Cadwaladr NHS University Health Boerd Wales Therefore please find enclosed two working action plans relating to this cage. The action plans will be scrutinized by the Assistant Director or Nursing as well as the Hospital Medical Director and will be monifored by the at the Quality and Safety Group to ensure timely progress. Yourc sincerely Mr Evan Mooro Exocutive Mlodical Director Enc
Sent To
- Betsi Cadwaladr University Health Board
- Welsh Ambulance Services NHS Trust
Response Status
Linked responses
2 of 2
56-Day Deadline
21 Oct 2016
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 the 13th of November 2014 commenced an investigation into the death of Pamela June Conway (DOB 13.6.43,DOD 8.11.14). The investigation concluded at the end of the inquest on the 23rd of August 2016 and | recorded a conclusion that the death was due to natural causes which were exacerbated by delayed medical treatment
Circumstances of the Death
The Circumstances of the death are that for multifactorial reasons there was a delay of around 21 hours before the deceased received antibiotics for an infected knee and that during the course of this period she went into irrecoverable septic shock_ Amongst the reasons for the above delay was the length of time it took for Mrs Conway to be discharged from the ambulance to the hospital on the 10th of October 2014. On this date the emergency department at Wrexham Maelor Hospital was extremely and despite an agreed handover time of 15 mins_ Mrs Conway waited in the ambulance for 2 hours and 50 mins. The longest waiting time on that date for a patient handover was one minute short of five hours Whilst this alone did not result in her death; it did form a of the cumulative delays by which Mrs Conway was denied the best chance of having her knee infection successfully treated and hence not going on to develop sepsis_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisations have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.