Gwilym Pugh Jones
PFD Report
All Responded
Ref: 2013-0239
All 1 response received
· Deadline: 20 Nov 2013
Coroner's Concerns (AI summary)
Clinician-requested tests were not conducted, resulting in a missed opportunity for diagnosis and treatment.
View full coroner's concerns
(1) Tests were not conducted despite being required by a clinician and this resulted in a missed opportunity to provide a diagnosis and treatment.
Responses
Action Taken
• The Corporate Governance Team was tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date. • Three policies are subject to fundamental review; this process will be completed by 31st March 2014. (AI summary)
• The Corporate Governance Team was tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date. • Three policies are subject to fundamental review; this process will be completed by 31st March 2014. (AI summary)
View full response
Dear Mr Rebello, Thank you for raising your concerns about the fact that Trust Policy had not been updated for some time and therefore was not representative of current practice. can confirm that the Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. Of the 120 Corporate Policies and Procedures currently in place , 117 are now in date_ Three policies are subject to fundamental review; this process will be completed by 31st March 2014. Between November 2013 and 12th February 2014, 50 policies have been reviewed and updated: can confirm that the policy that provided you with concern at the Inquest on 11th October 2013 was one of the first to be reviewed and updated. If can provide any further information, please do not hesitate to contact me at the above address_
Sent To
- Betsi Cadwaladr University Hospital Board
Response Status
Linked responses
1 of 1
56-Day Deadline
20 Nov 2013
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 19th of April 2013 I commenced an investigation into the death of Gwilym Pugh Jones (DOB 24.2.40, DOD 16.4.13). The investigation concluded at the end of the inquest on the 19th of September 2013. The conclusion of the inquest was Accidental Death and the medical cause of death was 1(a) Sepsis 1(b) Peritonitis and Toxic Mega Colon 1(c) Pseudomembranous Colitis (Clostridium Difficile Infection) 2 Diabetes Mellitus and Lacunar Anterior Circulation Stroke.
Circumstances of the Death
1. The Deceased had been admitted to the Wrexham Maelor Hospital on the 14th of March 2013 due to an apparent stroke. Whilst a patient at this hospital he developed symptoms which were suggestive of the Clostridium Difficile infection and on the 11th of April by an attending clinician that a stool sample be sent for analysis. This was not done.
2. At the final inquest hearing evidence was given by regarding the treatment of Mr Jones and he was unable to account for the failure of obtaining and testing a stool sample and he indicated that it is possible that the final outcome may have been different had this condition been diagnosed and treated sooner.
2. At the final inquest hearing evidence was given by regarding the treatment of Mr Jones and he was unable to account for the failure of obtaining and testing a stool sample and he indicated that it is possible that the final outcome may have been different had this condition been diagnosed and treated sooner.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.