Thomas Ithell
22 Jan 2024 · Coroner Kate Robertson · North Wales (East and Central)
The coroner's concerns
1. no Datix raised for missed follow up
“There was no Datix raised by anyone when the error (Mr [name redacted] being lost to follow up) was identified, either at the time of the appointment on 22 October 2022 when the error was identified or at any point thereafter”
2. no investigation into missed follow up
“There has been no investigation by the Health Board into how Mr [name redacted] came lost for follow up after his appointment on 5 November 2021”
3. lack of assurance of changes and learning
“There have been no assurances as to what, if any, changes and learning have been identified other than a tracking system for PSA monitoring”
4. time restraints preventing Datix completion
“Evidence was heard at the Inquest that time restraints on hospital staff had meant that Datix was not completed and that the system was not user-friendly”
5. assurances not supported when processes not followed
“I remain incredibly concerned that where matters are not raised in accordance with internal Health Board processes that assurances given to me previously in Prevention of Future Death Reports cannot be supported”
6. future Datix under‑reporting due to time constraints
“Furthermore, I am concerned that Datix reports will not be raised if time constraints prevents such, where the Health Board themselves often identify the Datix reporting system as the initiation of governance / investigation processes”