Coroner’s new warning to bosses at health board

FOR the third time in five months a coroner has warned that hospital bosses are putting lives at risk by failing to keep their promises.

John Gittins, coroner for North Wales East and Central, said he was concerned that the Betsi Cadwaladr University Health Board was “not following through what it promises to do”.

He was speaking at the end of an inquest in Ruthin into the death of former care home cook Susan Merton, who died at Glan Clwyd Hospital on August 23, 2019.

Announcing he would be issuing a Regulation 28 Prevention of Future Deaths Report, he said: “I shall be seeking further reassurances from those at a very senior level that when it is said that matters are going to be done, they are actually done.”

The inquest, reports North Wales Live, heard how the 65-year-old, of Woodland Drive, Greenfield, Flintshire, had had several hospital admissions over the previous 18 months and had to give up work because of severe stomach pains and vomiting. She was believed to have a stone in her bile duct. A postmortem examination revealed the cause of death as sepsis resulting from a biliary obstruction.

Following her death, a Serious Incident Review was conducted and the inquest heard that as a result some changes had been introduced, including closer monitoring of patient discharges by junior doctors. An action plan was adopted, but Mr Gittins said he was concerned to learn that although the Clinical Governance Committee had been due to review the plan in August this year, it had not done so.

Matthew Joyes, the board’s assistant director of quality assurance, outlined the new procedures and timetables for investigating incidents but agreed that the failure to review the action plan as promised was “unacceptable”.

Recording a conclusion of natural causes, Mr Gittins said he accepted there were exceptional conditions leading to Mrs Merton’s rapid deterioration and death, and he was somewhat reassured to hear of the changes made.

But he said he was concerned about the action plan not having been reviewed.

“When an organisation acts in a manner contradictory to their findings it must indicate to me that there is a risk, and when the nature of the organisation is dealing with patients that is a risk to life,” he said.