Dad-of-three died after medics failed to spot clot
TREATMENT COULD HAVE SAVED 42-YEAR-OLD’S LIFE
A FATHER-OF-THREE died because medics failed to diagnose a blood clot rather than failed to treat him, a coroner ruled.
Simon Willans passed away the day after he was sent home from Ysbyty Gwynedd, Bangor, after doctors said he had anxiety and low blood pressure.
A pathologist said the 42-year-old farm worker’s right calf was swollen due to deep vein thrombosis.
The four-day inquest heard that if recognised, anti-coagulant treatment may have saved his life.
North Wales senior coroner Dewi Pritchard Jones told the hearing Mr Willans died in an ambulance outside his home in Ty Croes, near Rhosneigr, Anglesey, on January 27 2016.
Mr Pritchard Jones, who recorded a narrative conclusion, said: “On the previous day he had been admitted to Ysbyty Gwynedd because of symptoms which caused concern.
“His examination on admission was adequate and appropriate tests were carried out.
“Due to the absence of records I cannot say if the subsequent examination was adequate or not.
“The interpretation of the information obtained was flawed and failed to diagnose what eventually killed him.
“If the information had been correctly interpreted he should have had further tests and treatment which might have prevented his death.”
He added: “Mr Willans died of a preventable natural cause which had not been diagnosed or treated when he was in hospital on the day before his death.”
Mr Pritchard Jones noted he did not find the doctor and other staff had neglected their duties.
He said assistant coroner Nicola Jones had already issued a prevention of future deaths notice due to her concerns that a similar tragedy could happen again.
Mr Pritchard Jones said he had considered the response of the Betsi Cadwaladr University Health Board Trust to the notice and that expert opinion had been sought in a Serious Incident Review.
He had been urged to include neglect in his conclusion by Sophie Cartwright, on behalf of Mr Willans’ family, but said this was not appropriate.
During the hearing in Caernarfon the coroner heard Mr Willans was referred to hospital by his GP, who had struggled to obtain an admission to Ysbyty Gwynedd.
Upon admission a nurse practitioner listed “orthostatic hypotension, viral illness, hyperthyroid and deep vein thrombosis/ pulmonary embolism” as possible causes.
His right calf was swollen some 3.5cms more than the left, and he had complained of being breathless and had suffered a recent loss of consciousness.
An ultrasound was taken but did not “image” the swollen calf, and blood gases were found to be abnormal. Blood tests indicated the possibility of a serious blood clot, while an ECG taken of his heart was abnormal.
He was later seen by a doctor but he did not keep written records of the consultation.
The misdiagnosis was the subject of a police investigation into a possible offence of gross negligence manslaughter, but a decision was made in 2017 by the Crown Prosecution Service not to pursue a criminal case.
After the hearing Dr Evan Moore, executive medical director at Betsi Cadwaladr University Health Board, said: “We offer our sincere condolences to Mr Willans’ family for their loss. We fully accept the coroner’s findings and apologise to Mr Willans’ family for the failings in his care.
“We have changed the way referrals and processes are managed within the ambulatory care unit. In addition, we are carrying out continuous performance reviews within the unit to ensure the best possible care for our patients.”