“There are a high number of referrals to the single rota'd on-call neurosurgical…”
Dated 10 Jun 2019, from the coroner for South Wales Central. Sent to 6 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
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Report put online after its 56 daysOrganisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
judiciary.uk put this report online on 23 Aug 2019, after the 56 days for replies had ended (5 Aug 2019). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated10 Jun 2019
- Deadline5 Aug 2019
- Published on judiciary.uk23 Aug 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Cardiff and Vale University Health Board | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Cwm Taf Morgannwg University Health Board | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Swansea Bay University Health Board | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Powys Teaching Health Board | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Hwyel Dda University Health Board | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Welsh Assembly Government | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— (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.referapatient.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?
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2019-0192
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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