Betsi Cadwaladr: Woman died after health board lost medical notes

A woman died after medical notes referring her for further tests were lost by a health board, an inquest has heard.

Jennifer Campbell, 73, died from pneumonia and sepsis at Ysbyty Gwynedd on 24 February 2022.

The senior coroner for north west Wales has now raised concerns that despite the slip-up no lessons appear to have been learned by staff.

Betsi Cadwaladr University Health Board has until 19 December to respond.

Senior Coroner Kate Robertson has said she was "not in any way satisfied" that concerns expressed by her in the past have not resulted in any improvements.

Her comments are included in a prevention of future deaths report addressed to the health board.

Ms Robertson recorded a narrative conclusion for Ms Campbell's death on 24 October this year, with obstructing gallstones given as a contributory factor.

Ms Campbell had an ultrasound scan of her abdomen on 25 October 2021, which showed gallstones and her GP referred her for a gastroenterology on 28 October.

Following a review, a gastroenterologist referred Ms Campbell for a combination of X-ray and endoscopy - but the referral was never received by the endoscopy department.

On 21 February 2022, Ms Campbell started to become unwell and was admitted to the emergency department two days later, but her condition deteriorated.

She died the following day from infection and pneumonia due to obstructing gallstones.

In the report Ms Robertson said there was no evidence of any formal investigation into how the referral was lost, and it was only during the inquest proceedings that the health board became aware of the situation - but even then it failed to launch an investigation.

The coroner said in the report: "Given that no investigation was conducted to understand how the issue may have occurred, there has been no learning, change or improvement to ensure it is not repeated, I have been provided with no assurances in this regard,"

She said that there was no evidence of an audit having taken place to see whether any other referrals had been lost.

The coroner added that she was aware that the matter of electronic notes and referrals replacing paper copies was being discussed nationally, but in the meantime patients' lives were being put at risk.

Carol Shillabeer, the health board's interim chief executive, said: "Our sincere condolences go out to the family of Ms Campbell for their loss.

"We accept the findings from the inquest and I will be meeting with the coroner as soon as possible to discuss her concerns."