“During the course of the evidence it was identified that:1”

The coroner’s concerns

– During the course of the evidence it was identified that:1. There was no Datix raised by anyone when the error (Mr Ithell being lost to follow up) was identified, either at the time of the appointment on 22 October 2022 when the error was identified or at any point thereafter; 2. There has been no investigation by the Health Board into how Mr Ithell came lost for follow up after his appointment on 5 November 2021; 3. There have been no assurances as to what, if any, changes and learning have been identified other than a tracking system for PSA monitoring; 4. Evidence was heard at the Inquest that time restraints on hospital staff had meant that Datix was not completed and that the system was not user-friendly. I have raised a number of Prevention of Future Death reports with the Health Board previously around investigation processes. I remain incredibly concerned that where matters are not raised in accordance with internal Health Board processes that assurances given to me previously in Prevention of Future Death Reports cannot be supported. Furthermore, I am concerned that Datix reports will not be raised if time constraints prevents such, where the Health Board themselves often identify the Datix reporting system as the initiation of governance / investigation processes.

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, 2024-0035

Added to Minute Book

8 Oct 2026

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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