Cerith Pugh
PFD Report
All Responded
Ref: 2016-0271
All 1 response received
· Deadline: 21 Sep 2016
Coroner's Concerns (AI summary)
Referrals to consultants were inappropriately handled by middle-grade doctors, and essential liver function tests were declined due to a rigid demand management policy, lacking a mechanism for clinical override.
View full coroner's concerns
That referrals to consultants at Withybush General Hospital are routinely being dealt with by middle grade doctors and, if in the opinion of the middle grade doctor, the matter then needs a referral to a consultant only then is the matter passed to a consultant. All consultant referrals should be seen by consultants in the first instance. Expert evidence received at the inquest described this practice as not being best practice.
That liver function tests were requested but the Health Board declined to undertake these for reasons of demand management on the basis tests had been done some three days earlier. Expert evidence received at the inquest was highly critical of this practice. Whilst 72 hour testing is in accordance with guidance contained in guidance from the Association for Clinical Biochemistry and the Royal College of Pathologists both documents are clear that the guidance must be capable of being overridden if clinically appropriate. There was no evidence of any mechanism to override the guidance or, if such guidance existed, that it was known to staff.
That liver function tests were requested but the Health Board declined to undertake these for reasons of demand management on the basis tests had been done some three days earlier. Expert evidence received at the inquest was highly critical of this practice. Whilst 72 hour testing is in accordance with guidance contained in guidance from the Association for Clinical Biochemistry and the Royal College of Pathologists both documents are clear that the guidance must be capable of being overridden if clinically appropriate. There was no evidence of any mechanism to override the guidance or, if such guidance existed, that it was known to staff.
Responses
Action Taken
The University Health Board has asked consultants to review their practice regarding consultant referrals. Medical staff have also been reminded that clinically justified test requests should be undertaken regardless of guidance about repeating tests. (AI summary)
The University Health Board has asked consultants to review their practice regarding consultant referrals. Medical staff have also been reminded that clinically justified test requests should be undertaken regardless of guidance about repeating tests. (AI summary)
View full response
Dear Mr Layton REGULATION 28: REPORT To PREVENT FUTURE DEATHS CERITH WYN Pugh Thank you for your report into the death of Cerith Wyn Pugh. As a result of your concerns we have issued your redacted report to the Hospital Directors (lead doctors) in each of the acute hospitals and through them we have asked each consultant to review their practice and to ensure that consultant to consultant referrals are directly reviewed by the consultant or that the review involves proactive delegation where appropriate, and consultant supervision. Some of our services are led by a single handed consultant on & particular site and this does provide some challenges when this individual is on leave. We are actively looking at the process we need to put in place in these cases so that specialist advice can always be accessed either by an alternative consultant on site, or a similar specialist on a different site_ We have also reminded medical staff that where test requests are made on clinically justifiable grounds these should be undertaken regardless of guidance regarding repeating tests and in the event of an investigation being declined by & provider the matter must be discussed with the Consultant whose team has ordered the request: SwyedlerdiCon ctaethol Adenai Yalwyl- Compcaie Oricee Yatvstn Bultling Cadeicen _ Haian Cocs Patcea Sant Hlacl Fh noc Jal- Kafan Darten, $ Davds Per , Jot $ !vel Fcad; Ktz @ernarjira Feet 038 Cacrlyroi . Sir G2frddr; 5431 333 Cana Lhcn, Carmarhensh 0 8431A#5 Frh Wvattet MChie: Execzizive K9t Mucra 2764' ieetw "'ryrgo Ry-e: Dda queitredc' Ewrd: :OCiyt' L'eci Priysso Hytel(s Hywei Dca Un Versty Xeoi Eobtd {9 jhe Opatstccc nsme H}uai Dfe Univelst; !*491 Heritt Eoera vie Buird iertid Frilyegol #tybei Dds+r a7 Ovichets &to Hvvt Cda :inivnnk tv Kexli: Anor' Ornrstae thtte #Bnn_32~' four dd'
hope this letter addresses the concerns that you identified in your report but if you require further information please do not hesitate to contact me
hope this letter addresses the concerns that you identified in your report but if you require further information please do not hesitate to contact me
Sent To
- Hywel Dda University Health Board
Response Status
Linked responses
1 of 1
56-Day Deadline
21 Sep 2016
All responses received
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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 23rd May 2014 I commenced an investigation into the death of Cerith Wyn Pugh then aged 62 who died on 20th May 2014. The investigation concluded at the end of the inquest on 27th July 2016. The conclusion of the inquest was a narrative one.
The deceased had disordered liver function tests from January 2014 onwards. They remained disordered in March 2014. Despite this the deceased was not admitted as an inpatient following his treatment for an orthopaedic problem in March 2014 and no MRCP (magnetic resonance cholangio-pancreatography) procedure was carried out on him as an inpatient. An MRCP would have revealed the presence of gallstones blocking the deceased’s bladder and common bile duct. This would have led to an invasive procesure to remove the gallstones.
The medical cause of death was: Ia multi-organ failure b ischaemic bowel disease II cholelithiasis, mechanical jaundice
The deceased had disordered liver function tests from January 2014 onwards. They remained disordered in March 2014. Despite this the deceased was not admitted as an inpatient following his treatment for an orthopaedic problem in March 2014 and no MRCP (magnetic resonance cholangio-pancreatography) procedure was carried out on him as an inpatient. An MRCP would have revealed the presence of gallstones blocking the deceased’s bladder and common bile duct. This would have led to an invasive procesure to remove the gallstones.
The medical cause of death was: Ia multi-organ failure b ischaemic bowel disease II cholelithiasis, mechanical jaundice
Circumstances of the Death
(1) On 29th March 2013 Cerith Wyn Pugh underwent surgery for a bowel obstruction. (2) His recovery was slower than anticipated and on 18th April 2013 suffered a cardiac arrest and underwent further surgery. (3) A CT scan indicated the possible presence of a stone in the bile duct and an ERCP was undertaken. Mr Pugh was subsequently discharged from hospital. He remained in poor health and there were further readmissions. (4) Mr Pugh was readmitted to hospital in March 2014 following a fall. His blood tests now showed a significantly disordered liver function. Liver function tests were requested but the request was declined for reasons of “demand management” as a previous report was issued less than three days previously. (5) The test results were not acted upon and Mr Pugh was subsequently discharged from hospital. Expert advice received at inquest suggested Mr Pugh should have remained in hospital for further treatment. (6) Mr Pugh was readmitted in May 2014 when he started to bleed from his ilieostomy. (7) Cerith Wyn Pugh passed away on 20th May 2014.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.