Rhian Margaret Roberts · Prevention of Future Deaths report

On the 1st of December 2020 I commenced an investigation into the death of Rhian Margaret Roberts (DOB 6.8.70 DOD 25.11.20) The investigation concluded at the end of the inquest on the 13th of July 2021. The conclusion of the inquest was one of misadventure with the cause of death being 1(a) Multi Organ Failure (b) Paracetamol Toxicity

The circumstances of Mrs Roberts’ death are that she was admitted to Glan Clwyd Hospital on the morning of the 22nd of November 2020 after being found unresponsive at home as a result of a presumed overdose.

Tests undertaken on admission to hospital established that she had extremely high levels of paracetamol in her system and although these results were available on the portal at 11.57, the treating clinicians in ICU did not become aware of this until the early hours of the following morning, when action was then taken by the administration of N-Acetylcysteine. Despite this treatment she continued to decline and passed away on the 25th of November 2020.

1. On arrival at ICU the clerking-in doctor requested a toxicology screen to include paracetamol and salicylate levels (notwithstanding that blood tests to include this were already in hand) and there was no evidence available at the inquest to establish whether or not the toxicology screen requested by the doctor was undertaken and if not why not.

2. An internal investigation by the health board following Mrs Roberts’ death rightly established that action needed to be taken to update or modify the SOP for communicating of life-threatening blood results directly with clinical areas and an action plan indicated that this would be completed by the 30th of June 2021. At the time of the inquest on the 13th of July, the proposed update remained in draft form only and had not yet been approved.

3. I am concerned that the continual delays in investigating adverse incidents, sharing learning and implementing actions following the same, create risks to patient safety.