Cancer patient went year without check-up, inquest told
BBCA prostate cancer patient went a year without a check-up because his referral to a consultant was lost.
An inquest into the death of Thomas Ithell also heard that when the error was spotted it was not recorded because staff at Wrexham Maelor Hospital were too busy.
The 77-year-old from Wrexham died in November 2022 after being admitted to hospital with shortness of breath.
Betsi Cadwaladr health board offered its condolences to Mr Ithell's family.
However, Assistant Coroner for North Wales East and Central Kate Robertson expressed concern that no investigation took place.
She has now submitted a Prevention of Future Deaths report to the health board in relation to Mr Ithell's case.
As well as concerns over the lack of an investigation, she also questioned how the patient's follow-up appointment was missed.
"There have been no assurances as to what, if any, changes and learning have been identified other than a tracking system for PSA monitoring," she wrote, referring to a type of blood test that helps diagnose prostate cancer.
She was also concerned to learn that the hospital's Datix system - used for reporting incidents such as Mr Ithell's - had been described as "not user-friendly".
Time constraints also sometimes prevented staff from completing these reports, thereby failing to trigger subsequent investigations by the board, the assistant coroner added.
"I remain incredibly concerned that where matters are not raised in accordance with internal health board processes that assurances given to me in previous Prevention of Future Deaths reports cannot be supported," Ms Robertson added.
Thomas Ithell was first diagnosed in September 2017 and had radiotherapy and hormone deprivation treatment.
However, he did not tolerate the hormone treatment well and was reluctant to continue with it.
His PSA levels were not tested after November 2021, and a letter from a nurse practitioner to a consultant seeking advice was lost.
Mr Ithell was not seen by a consultant until October, 2022, after an urgent referral by his GP following routine blood tests.
He died the following month and his cancer was recorded as the cause of death.
Betsi Cadwaladr University Health Board has until 18 March to respond to the coroner's concerns.
Its Executive Medical Director Dr Nick Lyons said: "On behalf of the health board, I offer my deepest condolences to Mr Ithell's family for their very sad loss.
"We note the coroner's findings that Mr Ithell died of natural causes and fully accept their wider points regarding the improvements needed in our incident investigation process.
"A review of that process is underway and this will be completed by the end of March, along with an improved training programme for our staff.
"We are committed to becoming an organisation that continually learns and improves - this is a major focus in our special measures improvement programme, with a number of changes being delivered this year."