Robert Erryl Jones · Prevention of Future Deaths report

On 14th May 2013 I commenced an investigation into the death of Robert Erryl Jones then aged 62. The investigation concluded at the end of the inquest on 18th March 2014. The conclusion of the inquest was a narrative conclusion namely that the deceased had died as a result of complications following necessary bowel surgery. The medical cause of death was:
1(a) multi-organ failure
1(b) peritonitis
1(c) post surgery for bowel cancer

(1) Mr Jones was admitted to Glangwili Hospital on 21st March 2013 for a bowel operation which was undertaken the following day. Mr Jones remained in hospital following the operation.
(2) Due to his declining health an emergency CT scan was arranged for the 8th May 2013.
(3) There was an unreasonable delay in making the results of the CT scan available to the ITU and Surgical teams involved in Mr Jones’ care. The report was not written up for some considerable time after the scan.
(4) When the results were made available there was a further unreasonable delay on the part of the ITU and Surgical teams in acting upon those results.
(5) This led to a significant delay in further surgery being performed.
(6) It became evident during the course of the inquest that this was not an isolated incident and this failure to pass over and act on CT scan results continues to occur.

That when a CT scan is performed the results should be made available promptly to the departments involved in the care of the patient and where appropriate the results should be acted upon without delay and within a reasonable time-scale.