UK Inquiry Tracker

John Morgan

PFD Report Partially Responded Ref: 2013-0372

Date of Report 17 December 2013

Coroner John Woolley

Coroner Area Cardiff & the Vale of Glamorgan

Response Deadline ✓ from report 11 February 2014

Mental Health related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Over-reliance on whiteboards rather than patient notes, the potential for human error to input incorrect information, and the use of a misleading DNR "red star" system pose risks to patient care.

View full coroner's concerns

(1) The Whiteboard (or PSAG) is in use throughout Wales as a quick reference guide to the patients on the ward. It was introduced as part of the “Transforming Care at the bedside “TCAB” programme. Dr Clinical Director for the University Hospital for Wales Board, confirmed that the information which is put on the whiteboard is a matter for local discretion. While the red “DNR” star system has been removed from the whiteboards in use in Cardiff and the Vale Local Health Board he could not say whether similar systems are not in use elsewhere in Wales.

(2) The whiteboard system is a useful reference point for patient care but there is a danger that the information held on the whiteboard is relied upon instead of the patient’s notes.

(3) Human error may mean that erroneous information is held on the whiteboard to the detriment of patient care.

(4) A similar DNR “red star” system may be in use on whiteboards in other Health Board areas in Wales with the possibility that a similar chain of events may occur elsewhere in Wales.

Responses

Welsh Government Devolved Administration

Action Planned
The Welsh Government requested that Health Boards and Trusts review the incident and make changes as appropriate. The Chief Medical Officer and Chief Nursing Officer will write to all Health Boards and Trusts in Wales to reinforce the need for robust systems where PSAG boards are in use. Welsh Government officials will also bring this to the attention of the 1000 Lives improvement service. (AI summary)

View full response

Mark Drakeford AC AM Y Gweinidog lechyd a Gwasanaethau Cymdeithasol Minister for Health and Social Services Llywodraeth Cymru Welsh Government Eich cyflYour ref Ein cyflOur ref MBIMD/0220/14 Mr €C J Wooley Assistant Coroner The Coroner's Court Central Police Station Cathays Park Cardiff Io February 2014 CF1O 3NN Dalr write further to your Regulation 28 Report in relation to the inquest into the death of Mr John Elvet Morgan. was extremely concerned to read circumstances of Mr Morgan's death whilst a patient at Barry Hospital and offer my sincere condolences to his family. As you describe in your report the Patient Status at a Glance (PSAG) board is useful as reference point for patient care. However, am in agreement with you, the information recorded must be accurate and staff must not rely solely upon this information when decisions about a patient's care and treatment expect Health Boards and Trusts to have suitable systems in place to ensure the safety of patients at all times and within all clinical areas_ Action The incident was reported to Welsh Government under the Serious Patient Safety Incident reporting process in September last year. The Chief Nursing Officer for Wales issued a request to all Nurse Directors within Health Boards and Trusts requesting consider the circumstances of the incident and make changes to their systems as appropriate. have further requested the Chief Medical Officer and Chief Nursing Officer write to all Health Boards and Trusts in Wales to remind them; where PSAG boards are in robust systems must be in place to safeguard patient safety and prevent a similar incident happening again. Bae Caerdydd Cardiff Bay English Enquiry Line 0845 010 3300 Caerdydd Cardiff Llinell Ymholiadau Cymraeg 0845 010 4400 CF99 1NA Correspondence Mark Drakeford @wales, gov.uk Wedi 'i argraffu ar bapur wedi'i ailgylchu '100%) Printed on 100% recycled paper LJstld' the making they use, from gsi.

Welsh Government officials will also bring this to the attention of the 1000 Lives improvement service , our national quality improvement programme, so that can reinforce the importance of healthcare staff accurate information within any future guidance provide_ This is a serious matter will ask the NHS Wales Quality and Safety Forum to discuss this at their next meeting to reinforce the learning: O11S Sy Mw TecpL4: Mark Drakeford AC / AM Y Gweinidog lechyd a Gwasanaethau Cymdeithasol Minister for Health and Social Services they using they very (o-ce97

Sent To

Cardiff and Vale University Health Board
Welsh Government Health and Social Care

Response Status

Linked responses 1 of 2

56-Day Deadline 11 Feb 2014

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 9th September 2013 I commenced an investigation into the death of John Elvet Morgan aged 88. The investigation concluded at the end of the inquest on 26th November 2013. The medical cause of death was: 1A Pulmonary Embolism in a man with dementia of Alzheimer’s type, and the conclusion of the inquest was that the deceased died from natural causes.

Circumstances of the Death

John Elvet Morgan was admitted to St Barruc’s ward, Barry hospital on 29th August 2013 for respite care. He suffered from Alzheimer’s dementia. On admission a red DNR (Do not Resuscitate) star was allowed to remain against his name on the whiteboard (or PSAG “Patient status at a glance Board”) on the ward. In fact there had been no agreement that he was “DNR” and the red star had been left over by mistake from a previous patient’s entry on the whiteboard. On 30th August 2013 John Elvet Morgan collapsed on the ward. He was not resuscitated by staff on the ward as they relied on the red “DNR” star on the whiteboard. When the paramedics arrived no yellow DNR form was found in the notes as of course one did not exist. The PM report showed that John Elvet Morgan had suffered a pulmonary embolism.