DAD SENT HOME FROM HOSPITAL DIED THE NEXT DAY
Inquest told of fatal blood clots
CHANCES were “missed” to prevent the death of a dad-of-three who was discharged from hospital suffering from blood clots, including one on his lung.
Simon Willans, 42, died the day after he was sent home from Ysbyty Gwynedd, Bangor after doctors said he had anxiety and low blood pressure, an inquest in Caernarfon heard.
Sophie Cartwright, counsel for the Willans family, said there was a failure to diagnose a pulmonary embolism – a blocked blood vessel in the lungs – and DVT.
Mr Willans, a former farm worker, of Bryngwran in Anglesey, died in January 2016 after he collapsed at the home of his parents Laurence and Lynn Willans.
Consultant Dr Hassan Mohammed told the inquest previously he didn’t suspect a lung clot because Mr Willans said he wasn’t breathless or dizzy.
But Prof Soloman Almond, brought in by the police after the death, told senior coroner Dewi Pritchard Jones there was a failure by the consultant to bring together “a number of pieces of information”. Mr Willans’ treatment had been “poor” in that regard.
Anxiety and orthostatic hypotension – a drop in blood pressure – had been diagnosed by the hospital – but Prof Almond said the latter “wasn’t a likely diagnosis”.
”To make that diagnosis I don’t believe was tenable,” he added.
Prof Almond said it was fair to describe Dr Mohammed’s alleged failings as “significant” but not “gross”.
Sian Hughes-Jones, head of nursing for unscheduled care and responsible for the ambulatory care unit, told the inquest procedures had changed since the tragedy.
Miss Cartwright said: “In October the matter was listed for inquest and at that stage, not withstanding the harm event, the Trust hadn’t completed a serious incident review.”
Ms Hughes-Jones said “that’s true,” but because there had been a police investigation.
Dr Emma Hosking, medical director at Betsi Cadwaladr Health Board’s Glan Clwyd Hospital, who chaired the serious incident review undertaken nearly two years after the tragedy, told the hearing Mr Willans’ previous collapses, breathlessness and abnormal blood gas “should have prompted a rethink”, after observations failed to find a clot or deep vein thrombosis (DVT).
The review panel felt Mr Willans shouldn’t have been discharged on the same day he attended the hospital, she added.
“Simon hasn’t been fully assessed while on the ambulatory care unit.
“The initial delay to his admission and incomplete assessment while he was there and poorly documented discharge process added up to some missed opportunities in his care,” Dr Hosking said.
Miss Cartwright, for the family, said: “There’s a whole raft of causative failures here.”
The inquest was adjourned after the evidence finished.
Mr Pritchard Jones said the conclusion would be a narrative verdict.