A coroner is calling on hospital bosses to spell out what plans are in place to ease pressures on staff in one of North Wales’s biggest emergency departments.
John Gittins, senior coroner for North Wales East and Central, says the current situation at Glan Clwyd Hospital is “unsustainable” and that more deaths could occur unless something is done about it.
He has issued the Betsi Cadwaladr University Health Board with a Prevention of Future Deaths report following the death of 82-year-old Margaret Kelly from Rhos-on-Sea.
Betsi Cadwaldr University Health Board, Executive Medical Director and Deputy Chief Executive, Dr Nick Lyons said: “On behalf of the Health Board, I once again offer my deepest condolences to Mrs Kelly’s family for their very sad loss.
"I would also like to reiterate how very sorry we are for the failures in her care.
"We take the Coroner’s findings very seriously and we will provide a comprehensive response to the concerns raised within the required timeframe.
"This will include details of actions that we have taken and plan to take as part of our detailed programme of work to improve standards of care within the Emergency Department at Glan Clwyd Hospital."
On 28 March, 2022, Mrs Kelly underwent surgery for a hernia repair, during which it is probable that her bowel was damaged.
An inquest last month heard that the following day she was in such pain that she attended the Emergency Department but was not seen by a doctor for several hours.
By the morning of 30 March her condition had deteriorated and further emergency surgery was carried out to repair the bowel.
In his PFD report the coroner said: “As a result of there being several missed opportunities to optimize her care and treatment, Mrs Kelly no longer had the resilience to recover from this procedure and she died at Glan Clwyd Hospital on the afternoon of the 31 March, 2022.”
Evidence was given that when she attended the hospital it was at Level 4 escalation, the highest possible level, and that was far from unusual.
“I am concerned that the pressure on clinicians and other staff is unsustainable and that delays in treatment will result in deaths,” said Mr Gittins.
He said he did not consider that operating practices within the department were a cause for concern, but he continued: “However, I am concerned that insufficient or ineffective strategic planning and support is being undertaken and I would therefore wish to hear from those responsible at an executive/ managerial level as to the steps which are being taken to reduce pressures within the department at Glan Clwyd.”
The Welsh Government is being urged to "step in immediately" by the Welsh Conservatives following the coroner's issuing of a Prevention of Future Deaths report.
Shadow Health Minister, Russell George MS said: “People who rely on Glan Clwyd Hospital will be rightly concerned by these comments from the coroner.
“The Labour Health Minister needs to get round the table with the hospital bosses and show the leadership that patients deserve to see from those running our Welsh NHS.”
The Welsh Government has launched a national programme to support the transformation of urgent and emergency care services across Wales, supported by £25m of extra funding each year.
Betsi Cadwaladr University Health Board is receiving almost £3m annually - and more than £400,000 has been awarded to develop emergency department waiting areas and improve the service for patients.
A Welsh Government spokesperson said “The health board are responsible for ensuring sufficient staffing levels at Glan Clwyd emergency department.
"Through the special measures process we have set out the improvements we expect to see in the performance of emergency departments, and we continue to closely monitor progress.
"The Health Minister is in regular contact with the health board chair and has made clear the improvements that are needed.
"She has also met with both the coroners to understand the improvements needed.”
The Health Board has until December 4 to respond to the coroner’s notice.
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