Kyle Hurst
26 Oct 2021 · Coroner John Gittins · North Wales (East and Central)
The coroner's concerns
1. delayed adoption of N-Acetylcysteine protocol
“accelerated administration of N-Acetylcysteine may be beneficial in the treatment of a but this has not yet been adopted into a Standard Operating Protocol despite this having been proposed in August 2021”
2. failure to implement risk mitigation procedures
“procedures to mitigate risks due to failure to act on diagnostic results would be approved and active by the 1st of October 2021, however at the time of concluding the inquest of [the deceased] on the 22nd of October, this had not been accomplished”
3. delayed implementation of changes
“I am concerned that the Health Board continue to fail to achieve changes in a timely manner, even in circumstances where they have set their own timeframe and that as a result of this lives are being put at risk”
Responses
2021-0359-Response-from-BCUHB_Published.pdf ↗· Betsi Cadwaladr University Health Board
Stated action · 31 January 2022
“therefore intend to take executive decision to approve this procedure outside of the normal governance process and this will be completed no later than the 31 January 2022”