UK Inquiry Tracker

Sally Ellison

PFD Report All Responded Ref: 2015-0163

Date of Report 27 April 2015

Coroner John Gittins

Coroner Area North Wales (East & Central)

Response Deadline est. 22 June 2015

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 22 Jun 2015

Coroner's Concerns (AI summary)

There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing and reporting service is urgently needed.

View full coroner's concerns

_ That although it was clear upon her admission to Glan Clwyd on the 29th of May 2012 at around 16.00 hours, that she was suffering from a severe form of Community Acquired Pneumonia, and that this was recognised as being an atypical pneumonia that same evening; no urine sample was sent for analysis until overnight on the 315 of with the confirmation of it positive for legionella coming on the morning of the 1st of June. It is the case that treatment was already being given for the possibility of legionella from the 30th of May, but this was not against a confirmed diagnosis and therefore optimal treatment may have been delayed. 24th , May being

Not only should consideration therefore be given to undertaking tests at an earlier stage but there should also be available to fhe hospital a rapid testing and reporting service, either preferably a service within North Wales or utilising options within organisations geographically closer and more accessible than those in Cardiff

Responses

NHS Wales NHS / Health Body

Action Planned
NHS Wales, through the Pathology Clinical Programme Group, has reviewed the process for requesting urgent samples from primary care and is distributing a memorandum to GPs and Practice Managers with instructions on labeling and transportation to minimize delay, along with contact numbers for laboratories. (AI summary)

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Dear Mr. Gittins, Rereport for the_ Prevention of Future_Deaths Inquest of Sally Ellison Following the conclusion of the above inquest you sent me report pursuant to Regulation 28 of the Coroners (Investigations) regulations 2013. In this Report you reported that the MATTERS OF CONCERN were as follows:- That urgent blood tests were requested by _ (GP) at lunchtime on 28th of April 2012, despite these noted as urgent; the samples were not conveyed to the laboratory for analysis after collection by the district nurse, until routine collection of samples was undertaken from Colwyn Bay Community Hospital later that afternoon. As a result the delay in analysis meant that results were not provided to surgery until the following morning: Whilst the evidence indicates that changes have been made within the laboratory at Glan Clwyd to enable the immediate reporting of all cases where the CRP is greater than 300, there was no evidence available to confirm that all urgent tests could be expedited by district nurses thus alleviating potentially life threatening delays in treatment: From this, you requested that actions should be taken to prevent future deaths. Because of the Pathology Clinical Programme Group (CPG) , and in particular the Governance section of the CPG, has reviewed the process for the requesting of urgent samples primary care across BCUHB. This process has explained in memorandum that will be distributed electronically to all GPs and Practice Managers supported by BCUHB. The memorandum includes the correct process for the labeling of samples and its transportation to minimise delay: It also includes the relevant departmental telephone numbers for the laboratories across North Wales to ensure that the sample requester can warn the relevant department of the samples imminent arrival: 27th the yet being have this, from been

Our colleagues in the Primary Care Support Unit will enable this distribution which will take place during the week commencing Monday June 2015. will write to you subsequently to confirm this distribution has taken place.

Sent To

Betsi Cadwaladr University Health Board

Response Status

Linked responses 1 of 1

56-Day Deadline 22 Jun 2015

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 7th of June 2012 commenced an investigation into the death of Sally Ellison (DOB 3.8.57, DOD 1.6.12). The investigation concluded at the end of the inquest on the of April 2015 and recorded a conclusion of an Accidental death

Circumstances of the Death

The Circumstances of the death are that Mrs Ellison contracted the legionella infection whilst on holiday in Tunisia in Mid-May 2012 and her death on the 1s 0f June 2012 was due to 1(a) Cardiac Arrest (b) Multi Organ Failure (c) Legionella Pneumonia

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_