Eva Wheeler
21 Dec 2021 · Coroner Rachel Knight · South Wales Central
The coroner's concerns
1. failure to contact emergency ambulance
“The communication error between staff led to a failure to contact an emergency ambulance to transfer a critically ill patient to a major hospital”
2. inappropriate patient feeding before surgery
“A consequence of the communication error (above) was that Mrs [name redacted] was given lunch, rather than being kept nil by mouth prior to proposed surgical assessment”
3. delayed specialist consultation
“The on-call Medical Registrar at Prince Charles Hospital was contacted for advice, since doctors do not work at YCC overnight”
Responses
2021-0424-Response-from-Cwm-Taf-Morgannwg-University-Health-Board_Published.pdf ↗· Cwm Taf Morgannwg University Health Board
Stated action · 14 January 2022
“The communication error between staff led to a failure to contact an emergency ambulance to transfer a critically ill patient to a major hospital. Since this incident, computerisation has largely replaced written notes in this Trust, and evidence from staff did not satisfy me that any changes were embedded on the ground. I am concerned that there is not a clear and robust process in place for documenting, requesting and chasing-up emergency ambulances throughout YCC.”