Eifion Huws
8 Jun 2023 · Coroner Kate Sutherland · North West Wales
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of electronic access to hard copy notes
“During the Inquest evidence was heard that [the deceased]'s GP had made a 'very urgent' referral to the Single Point of Access and Allocation within BCUHB on 13 May 2022 indicating that on the background of attempts at ending his life, he was extremely concerned that [the deceased] was experiencing deterioration in his mental state. This document was contained within the hard copy set of notes held by the Psychiatric Liaison Team. When [the deceased] attended at the Emergency Department the following day, on 14 May 202”
2. failure to treat lack of electronic notes as improvement priority
“During the evidence it was accepted that 'a' above was not a consideration for improvement as part of the Health Board's investigation and so was not an action within the Action Plan upon which it could make improvements or plan to make improvements. It is surprising that the Health Board did not consider this as an issue which required further consideration and improvements in its learning and improvement.”
3. delayed investigation completion and dissemination
“I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety.”
This report
“I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner.”