Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Rhian Roberts · 14 Jul 2021 · John Gittins, North Wales (East and Central)
“I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety.”
judiciary.uk/prevention-of-future-death-reports/rhian-roberts
What was promised
Stated action 1 · response to Rhian Roberts (14 Jul 2021) · stated timescale: none stated
“On arrival at ICU the clerking-in doctor requested a toxicology screen to include paracetamol and salicylate levels (notwithstanding that blood tests to include this were already in hand) and there was no evidence available at the inquest to establish whether or not the toxicology screen requested by the doctor was undertaken and if not why not.”
judiciary.uk/…/2021-0242-Betsi-Cadwaladr-University-Health-Boar…
Stated action 2 · response to Rhian Roberts (14 Jul 2021) · stated timescale: 20 July 2021
“An internal investigation by the health board following Mrs [name redacted]' death rightly established that action needed to be taken to update or modify the SOP for communicating of life-threatening blood results directly with clinical areas and an action plan indicated that this would be completed by the 30th of June 2021.”
judiciary.uk/…/2021-0242-Betsi-Cadwaladr-University-Health-Boar…
Stated action 3 · response to Rhian Roberts (14 Jul 2021) · stated timescale: April 2021
“A new process to support the services to deliver timely investigations was commenced in April 2021.”
judiciary.uk/…/2021-0242-Betsi-Cadwaladr-University-Health-Boar…
What recurred
- 8 Jun 2023 · Eifion Huws · Kate Sutherland · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Rhian Roberts · 14 Jul 2021
“I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety.”
Later · Eifion Huws · 8 Jun 2023
“I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner.”
What happened next
No web check of the stated actions has been published for this chain.