“The abnormal blood results were telephoned through to the emergency department as…”
Dated 14 Jun 2024, from the coroner for North Wales (East and Central). Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 9 Aug 2024.
Organisations 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.
- Report dated14 Jun 2024
- Deadline9 Aug 2024
- Published on judiciary.uk25 Jun 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Betsi Cadwaladr University Health Board | Response publishedPublished on judiciary.uk in June 2024. |
The coroner’s concerns
– The abnormal blood results were telephoned through to the emergency department as required by the current system within an hour of the blood being taken to highlight the abnormal results. The results were available on the system; but they were not initially documented by the emergency department following the telephone call. They were not actioned, nor were they noted until many hours later until a clinician actively considered the electronic emergency department medical records for Mr Thompson. There is no electronic or IT method or system by which the laboratory can send the results to the emergency department quickly and efficiently with an alert to indicate abnormal results. Instead, the system relies on person-to-person discussions and for this to then be escalated, as necessary.
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, 2024-0323
- 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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