A review has found that a coroner was not fully informed of four patient deaths at a vascular service in north Wales. A independent panel has urged Betsi Cadwaladr University Health Board to improve its vascular service at Ysbyty Glan Clwyd in Denbighshire.
It comes after the health board commissioned reports after there were concerns about the development of a new hub at Ysbyty Glan Clwyd. The new model, which was reorganised in 2019, saw complex procedures at Wrexham Maelor Hospital in Wrexham and Ysbyty Gwynedd in Bangor being moved to the vascular service to the hospital in Bodelwyddan.
The findings of the independent panel, which was commissioned by the health board, follows an earlier report by the Royal College of Surgeons (England), which made 27 recommendations to improve vascular services in the health board area. The report presented nine urgent recommendations and other issues to the health board, including the fact there were too many patients being transferred to the centralised hub, as well as a lack of vascular beds and frequent delays in transfers.
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Another report, which was published in February of last year, focused on clinical records of 44 patients which dated back to 2014 to July 2021. The report added five more urgent recommendations in relation to "patient safety risk". The latest report which was published on Tuesday, January 31, further added nine recommendations, five of which were urgent.
The study, which looked at patient case notes, included recommendations such as reviewing consent practices as a way to ensure that they are "consistent with the legal and regulatory framework", improving communication with patients and families, as well as ensuring staff engagement and understanding of the vascular system was in place. It also noted that four deaths had not been fully declared to the coroner.
In response to the publication, Betsi Cadwaladr University Health Board's interim deputy CEO and executive medical director Dr Nick Lyons, offered his "sincere apologies" to patients. In a statement, he said: "Firstly, I would like to reiterate my sincere apologies to those patients who did not receive the first class service they deserve, some of whose cases were covered in this report.
"Following the Royal College of Surgeons’ report into our vascular service published in January 2022, which crucially spanned records from as early as 2015 up to July 2021, we were honest and said we needed to do better. I am satisfied the majority of the recommendations outlined in this review have already been completed and work continues on those outstanding.
"The hard work of our staff has resulted in a service which I believe is now serving the people of North Wales. We know we have more work to do and there has been a tremendous amount of training done on things like record keeping. Our partnerships with the Liverpool Vascular Network and the Royal Stoke University Hospital have given us vital cover for complex aortic cases and for those out of hours cases we infrequently require help with. Regular meetings of our hub and spoke operational management teams have also led to greater assurance we are prepared, not only for our routine clinics and inpatient activity, but any issues regarding staffing and cover across our sites.
"While I would be the first to acknowledge there is still much to do, I believe the vascular service across North Wales is in a far better place than it was prior to the invited RCS review and is providing good outcomes for our public. I also remain convinced the hub and spoke model is the best way of serving those patients in our communities who require vascular treatment, not least because it allows our clinicians to retain their skills and, therefore, keep the vast majority of vascular services within the area we serve."
The Welsh Government has placed Ysbyty Glan Clwyd under 'targeted intervention' and are specifically focusing on the hospital's vascular service. In response to the publication of the review, the health minister for Wales Eluned Morgan MS said: "When the RCS report was published, I expressed my disappointment and concern at its findings. I know local people and Senedd Members shared my concerns and wanted them addressed along with the future of this service.
"The report makes 27 recommendations, in relation to effectiveness of clinical pathways; clinical governance, including consent and decision-making, accountability and professional practice; person-centred care; team working, including the multi-disciplinary team; complex pain management; palliative care; education and learning; discharge, and necessary and appropriate follow up and aftercare plans.
"I do not underestimate how challenging it has been for the health board to address these issues, but they must provide assurance that they are addressing, or have already addressed, the recommendations within this report as a matter of urgency. The people in North Wales must be assured that BCUHB have rectified the issues identified, improved pathways and outcomes."
Other political parties have also expressed their concerns. The Welsh Conservative Shadow Minister for North Wales Darren Millar MS said: "Many people in North Wales will be concerned to read today’s report into vascular services in the region and to learn that the coroner was not fully informed of four patient deaths from the 47 cases which were reviewed.
"It begs the question as to how many other deaths, both in the vascular service and other clinical discipline, have not been appropriately referred to the coroner for consideration? The findings of chaotic patient record-keeping and a failure to fully implement recommendations from previous scathing reports is alarming, puts patients at risk and suggests that Betsi is not learning from its mistakes.
"The Labour Government must urgently explain what action it is taking to ensure that the Health Board makes the necessary changes and so that patients across the region can access the safe and effective care that they deserve."
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