Glenys Button · Prevention of Future Deaths report

On the 8th November 2018 an inquest was opened into the death of Glenys Button. The investigation was concluded at a hearing on the 6th June 2019. The conclusion was that Mrs Button had suffered an accidental death, following a fall backwards onto a wooden floor at home.

Glenys Button was aged 78 on the 5th November 2018 when she died at the Royal Glamorgan Hospital. She had sustained a head injury involving a basal skull fracture and an unusual pneumocephalus and brain bleed, following a likely accidental backwards fall onto a wooden floor at her home address on 2nd November 2018. She had a number of co-morbidities including ischaemic heart disease, diabetes, osteoarthritis and chronic obstructive pulmonary disease.

There is no neurosurgery ward at the Royal Glamorgan Hospital, therefore trauma doctors there (and similarly in other outlying units throughout South and West Wales) rely heavily upon emergency advice from the on-call neurosurgeons at the University Hospital of Wales in Cardiff as to the treatment and management of head and brain injury patients such as Mrs Button. It is the neurosurgeons who make the final decision as to whether to transfer the patient to the UHW for intervention.

In this case, there were frustrating delays in contacting the on-call neurosurgery specialist registrar, there was confusion over whether Mrs Button was a suitable candidate for transfer to the unit in Cardiff for treatment, there was conflict over the discussion of her co-morbidities and there was inadequate written evidence of the various conversations. Following a deterioration in her condition, Mrs Button was firstly accepted, then rejected for transfer to Cardiff (mid-journey) and was ultimately managed conservatively on a trauma and orthopaedics ward at the RGH, where she succumbed to her devastating injuries.

(1) There are a high number of referrals to the single rota’d on-call neurosurgical specialist registrar every day. The system for making and receiving the referrals is not fit for purpose, with inefficient delays, miscommunications and confusion occurring. The use of the UHW switchboard and bleeping the doctor is archaic, and does not utilise technology as it should. Further, if the on-call doctor is in surgery or dealing with an emergency, there is no back up doctor to field the referrals, which can often be time critical.

(2) There is a similar situation with spinal specialists, where Cardiff has the experts and the outlying hospitals contact them for advice. A pro forma document has been designed which is filled in by local doctors and sent to a generic email address for the spinal team. The pro forma is considered and completed by the specialists and emailed back with answers. The only telephone call (to a direct number rather than the switchboard) involves the outlying hospital notifying the spinal team to expect an email referral. This system reduces the risk of delay and miscommunication, and provides a single, collaborative document for a patient’s notes. Could this be a better system to be used with neurosurgery referrals as a short-term measure?

(3) There is a cutting-edge system used in Bristol, in Southmead Hospital, called www.refapatient.org which uses modern technology to assist in referring patients between departments/hospitals. The website is self-explanatory. Could this be a better system to be used widely across the NHS in Wales in the longer term?