Cancer patient went year without check-up, inquest told
A 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.
Assistant Coroner for North Wales East and Central, Kate Robertson, has 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.
Source: BBC News, 27 January 2024