Concerns raised 2
Delays in endoscopy for urgent non-suspected cancer referrals View source Delays in endoscopy for urgent suspected cancer referrals View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rory Colin Williams · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rory Colin Williams was referred for urgent suspected cancer investigations in May 2023 after experiencing dysphagia and weight loss, but did not attend a scheduled outpatient appointment and later missed a recommended repeat endoscopy. Adenocarcinoma was identified in July 2024, and he died in hospital on 10 August 2024 after being admitted with severe abdominal pain. The report raised concerns about delays, staffing shortages, inadequate infrastructure, lengthy waiting times, and inadequate corporate risk recognition within the gastroenterology and endoscopy service.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in endoscopy for urgent non-suspected cancer referrals
Wider context from the report “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-
a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018.
b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why.
c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks.
d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023.
e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023.
f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known.
g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.
” Source location Rory Colin Williams · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in endoscopy for urgent suspected cancer referrals
Wider context from the report “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-
a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018.
b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why.
c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks.
d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023.
e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023.
f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known.
g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.
” Source location Rory Colin Williams · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a temporary endoscopy unit at Ysbyty Gwynedd to provide additional diagnostic capacity.
Verbatim wording from the response “As an immediate mitigating action, a temporary endoscopy unit has been established at Ysbyty Gwynedd, planned to be operational from mid-March 2026 for an anticipated period of approximately five months. This facility has been introduced to increase diagnostic capacity and is expected to enable the delivery of in excess of 1,500 additional endoscopy procedures, supporting patients who have been waiting longer than intended for investigation. We are also progressing whether further contracts for additional outsourcing activity are required for the new financial year.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess whether further outsourcing contracts are required for the new financial year.
Verbatim wording from the response “As an immediate mitigating action, a temporary endoscopy unit has been established at Ysbyty Gwynedd, planned to be operational from mid-March 2026 for an anticipated period of approximately five months. This facility has been introduced to increase diagnostic capacity and is expected to enable the delivery of in excess of 1,500 additional endoscopy procedures, supporting patients who have been waiting longer than intended for investigation. We are also progressing whether further contracts for additional outsourcing activity are required for the new financial year.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardise referral, triage and prioritisation pathways across the Health Board.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Model whole-system capacity and demand to inform endoscopy access and service planning.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement interim capacity-enhancing measures to improve access while longer-term solutions develop.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue clerical and clinical validation of patients awaiting endoscopy to refine referral pathways.
Verbatim wording from the response “The Health Board has been working closely with national colleagues over the last three months to ensure both clerical and clinical validation of those awaiting endoscopy. Over 1000 referrals have been reviewed and approx. 40% have been removed from the waiting list either because it is felt that scope was not clinically indicated or that a further review or test may help decide whether the scope, or a different form of treatment, was needed. This work will be continued and is pivotal in the design of effective referral pathways.” Source location Response from Betsi Cadwaladr University Health Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen referral management by introducing specialist nurse triage for all urgent cancer referrals.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr University Health Board
Open published response
Concerns raised 1
Unavailability of out-of-hours emergency endoscopy View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Vivienne Greener · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of out-of-hours emergency endoscopy
Wider context from the report “1. An out of hours emergency endoscopy is still not available at Glan Clwyd Hospital or in this area of North Wales as the provision has ‘collapsed’ at Wrexham Maelor Hospital, so no referrals can be made;
” Source location Vivienne Greener · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a newly appointed gastroenterologist to the upper gastrointestinal rota from April 2024.
Verbatim wording from the response “A new Gastroenterologist has been appointed in YGC and will start in April 2024 and they will be part of an upper GI rota.” Source location Response from Betso Cadwaladr University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a suitable out-of-hours endoscopy rota.
Verbatim wording from the response “Provision of out of hours endoscopy remains under review given the historical and on-going concerns and the teams will be working towards the development of a suitable rota.” Source location Response from Betso Cadwaladr University Health Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Glan Clwyd Hospital lacks sufficient demand to support a 24/7 emergency endoscopy service under NICE guidance.
Verbatim wording from the response “Out of hours emergency endoscopy not available at Glan Clwyd Hospital or in this area of North Wales” Source location Response from Betso Cadwaladr University Health Board
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Workforce challenges at Wrexham Maelor Hospital prevent continuation of cross-site cover for urgent upper gastrointestinal bleeds.
Verbatim wording from the response “As you identified, Wrexham Maelor Hospital (WMH) would previously take over patients with urgent upper gastrointestinal bleeds, once they were stabilised at YGC. This cross-site cover has stopped due to workforce challenges at WMH. Currently the clinicians will adopt the recommendations set out in the Upper GI Bleeding – Management and Principles of Care at YGC ‘pathway. The pathway outlines the following:” Source location Response from Betso Cadwaladr University Health Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Resuscitation, haemorrhage management, critical care monitoring and escalation pathways can stabilise most upper gastrointestinal bleeding until endoscopy.
Verbatim wording from the response “Optimal resuscitation measures, excellent major haemorrhage management, close critical care monitoring (and use in extremis of the Sengstaken tube for variceal bleeds) can stabilise most Upper GI bleeding until endoscopy can be done at the earliest next opportunity. On very rare occasions when patients cannot be stabilised, and patients display evidence of ongoing life threatening bleeding such as overt large volume bleeding, haemodynamic compromise, shock, NEWS scores >8, or high Glasgow Blatchford scores the following key staff should be contacted - the on Call Consultant Physician, Surgeon, ITU team, and ED consultant to lead on the management and coordinate care.” Source location Response from Betso Cadwaladr University Health Board
Open published response
11 Jul 2018 Rita Elizabeth GILES · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1
Insufficient ERCP capacity for urgent requirements View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Rita Elizabeth GILES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rita Elizabeth GILES underwent an endoscopic retrograde cholangiopancreatography after delays and was reported not to have recovered, dying a few days later. The concerns included unnecessary transfers without supporting paperwork, failure to follow the Trust’s Transfer Policy, limited ERCP capacity, and failure to recognise the urgency associated with her sepsis; it was suggested that earlier transfer to the Royal Sussex County Hospital might have enabled urgent treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient ERCP capacity for urgent requirements
Wider context from the report “(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork.
(2) The Trust’s own Transfer Policy not adhered too in any respect.
(3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later.
(4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays . The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement .
There was a failure to appreciate that as she was already septic when she came in the matter was urgent.
From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round.
” Source location Rita Elizabeth GILES · Prevention of Future Deaths report
Open source report
26 Jan 2018 Mrs. Riaz Begum · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Unavailability of ERCP procedure lists during consultant annual leave View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mrs. Riaz Begum · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs. Riaz Begum developed a bile leak and sepsis following a laparoscopic cholecystectomy, and later developed acute pancreatitis after an ERCP to repair the leak. She died on 16 July 2017 despite treatment for sepsis and multi-organ failure. Concerns included delays in CT-guided drainage and ERCP, insufficient radiology capacity, inadequate escalation, and the potential impact of consultant leave on ERCP availability.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of ERCP procedure lists during consultant annual leave
Wider context from the report “(3) I am further concerned by the evidence of ████████ that after took annual leave on the 3rd July, there were no further lists for ERCP procedures until his return on the 11th July . Whilst there may have been other surgical consultants available to review Mrs. Begum whilst he was on leave, his evidence was that once a bile leak was confirmed the ERCP should have taken place and this on his account would not have been possible for 6 days after the leak was diagnosed . I found that this delay played a part in the development of acute pancreatitis in Mrs. Begum and I am concerned that any other delays caused by annual leave being taken may cause further delays for ERCP’s for a patient which creates a risk of future deaths.
” Source location Mrs. Riaz Begum · Prevention of Future Deaths report
Open source report
23 Mar 2016 June Elsie Parkes · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 2
Delays in undertaking urgent or emergency endoscopies in hours View source Unavailability of urgent or emergency endoscopy out of hours View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
June Elsie Parkes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
June Elsie Parkes became unwell with symptoms of an upper gastrointestinal bleed and was admitted to hospital on 14 December 2014. She later deteriorated and died shortly after being transferred to Huddersfield Royal Infirmary on 17 December 2014. The concerns included delays and gaps in systems for urgent or emergency endoscopy and surgery, monitoring and escalation, record keeping, and the transfer of critically ill patients.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in undertaking urgent or emergency endoscopies in hours
Wider context from the report “A. The provision and systems in place to identify and undertake urgent or emergency endoscopies at Calderdale royal hospital “in hours”
i) From the details set out in section 4, there appears to have been various issues which resulted in a significant length of time elapsing between Mrs Parkes being identified as requiring an urgent endoscopy, and it actually being carried out, which didn’t reflect the timescale recommended within current NICE guidance .
ii) The present protocol gives guidance for patients that present with a suspected upper GI bleed out of hours but does not provide guidance for “in hours”
iii) the present protocol does not provide guidance to identify a patient who may have suffered a rebleed post endoscopy and what measures should be considered
” Source location June Elsie Parkes · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of urgent or emergency endoscopy out of hours
Wider context from the report “(2) There is no provision at Calderdale Royal Hospital to undertake urgent or emergency endoscopies “out of hours” , if a patient is deemed to require such procedure and transfer to Huddersfield Royal Infirmary is required.
In light of no facility to undertake out of hours endoscopies, a number of doctors who gave evidence at the inquest, stated that present protocol guidance results in patients often being transferred in a critical condition, and there appeared to be a generalised view that if such facilities were not available 24 hours a day, the time to transfer such patients was when a further rebleed was suspected and whilst the patient remained stable
” Source location June Elsie Parkes · Prevention of Future Deaths report
Open source report
20 Jan 2016 Leslie Alan Summerfield · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Unavailability of urgent endoscopy at Trafford View source Failure to provide urgent endoscopy at the Manchester Royal Infirmary View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Leslie Alan Summerfield · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Leslie Alan Summerfield was admitted to Trafford General Hospital in late June 2015 and suffered a subdural haematoma following relatively minor trauma during the last two weeks of his life; the pathologist concluded that the injury occurred while he was in hospital. Concerns were raised about the lack of urgent endoscopy at Trafford, the ambulance transfers to and from Manchester Royal Infirmary, and the potential for this to have caused unnecessary discomfort or weakened him.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of urgent endoscopy at Trafford
Wider context from the report “The Consultant Physician giving evidence to me indicated that she felt he needed an urgent endoscopy and that such a facility used to be available on site at Trafford, and indeed the equipment and staff members are still there, but only for use as a planned facility, not as an urgent request . If this is the case, is it safe to continue to treat patients with this type of illness at a hospital where the Management has withdrawn this essential service ? In fact he was transported by ambulance to and from the Manchester Royal Infirmary despite the fact that he was a very sick man. The urgent endoscopy was not done at the MRI and he was sent back to Trafford for a “planned” endoscopy to take place.
At the very least this caused him considerable unnecessary discomfort, and at worst may have weakened him such as to aggravate his pre-existing co-morbidities.
” Source location Leslie Alan Summerfield · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide urgent endoscopy at the Manchester Royal Infirmary
Wider context from the report “The Consultant Physician giving evidence to me indicated that she felt he needed an urgent endoscopy and that such a facility used to be available on site at Trafford, and indeed the equipment and staff members are still there, but only for use as a planned facility, not as an urgent request. If this is the case, is it safe to continue to treat patients with this type of illness at a hospital where the Management has withdrawn this essential service? In fact he was transported by ambulance to and from the Manchester Royal Infirmary despite the fact that he was a very sick man. The urgent endoscopy was not done at the MRI and he was sent back to Trafford for a “planned” endoscopy to take place.
At the very least this caused him considerable unnecessary discomfort, and at worst may have weakened him such as to aggravate his pre-existing co-morbidities.
” Source location Leslie Alan Summerfield · Prevention of Future Deaths report
Open source report
1 Jun 2015 Ronald Alfred Smith · Prevention of Future Deaths report London (East)
View report summary
Concerns raised 2
Failure to make flexible sigmoidoscopy equipment available out of hours View source Lack of a clearly communicated and accessible protocol for out-of-hours access to flexible sigmoidoscopy equipment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Ronald Alfred Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ronald Alfred Smith was admitted to Queen’s Hospital with a sigmoid volvulus causing bowel obstruction and bowel ischaemia, and died on 2 February 2014 before a flexible sigmoidoscopy could be performed. The principal concern was that staff could not access the equipment out of hours, and that no clear protocol for doing so had been established despite the identified need.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make flexible sigmoidoscopy equipment available out of hours
Wider context from the report “there was a failure in this case to access a flexible sigmoidoscope out of hours . This item of surgical equipment was not available to the surgical registrar who considered that this was the only intervention that may have benefitted the patient.
Mr Smith’s death occurred in February 2014. The Trust’s root cause analysis report identified the need for a clearly communicated and accessible protocol for access to flexible sigmoidoscopies out of hours. Notwithstanding the period of 16 months which has elapsed since Mr Smith’s death there is still no protocol in place at the Trust. I consider that action should be taken to expedite a clear procedure for such equipment to be available to staff out of hours .
” Source location Ronald Alfred Smith · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a clearly communicated and accessible protocol for out-of-hours access to flexible sigmoidoscopy equipment
Wider context from the report “there was a failure in this case to access a flexible sigmoidoscope out of hours. This item of surgical equipment was not available to the surgical registrar who considered that this was the only intervention that may have benefitted the patient.
Mr Smith’s death occurred in February 2014. The Trust’s root cause analysis report identified the need for a clearly communicated and accessible protocol for access to flexible sigmoidoscopies out of hours . Notwithstanding the period of 16 months which has elapsed since Mr Smith’s death there is still no protocol in place at the Trust . I consider that action should be taken to expedite a clear procedure for such equipment to be available to staff out of hours.
” Source location Ronald Alfred Smith · Prevention of Future Deaths report
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Includes failures of procedure access, dedicated staffing or equipment specifically required to provide urgent or out-of-hours endoscopy.
