Woman who died after fall in Llandudno was ‘failed at every level’

Janet Margaret Jones, from Moelfre, died aged 61 on August 20, 2018 after falling down a flight of stairs two days earlier. 

She was initially transferred to Ysbyty Glan Clwyd, Bodelwyddan, and later the Royal Stoke University Hospital, where she died after suffering a cardiac arrest.

At a full inquest in Ruthin today (March 27), John Gittins, senior coroner for North Wales East and Central, said a number of issues “trouble me and, rightly, have troubled her family” regarding the care she received.

Her son, Vince, said he believed she was “failed at every level, and not given the very basic of care and treatment that she or anyone else would expect or deserve”.

Mr Gittins recorded a narrative conclusion regarding the death of Mrs Jones, who was born in Birkenhead and worked as a hairdresser.

It was heard that, in December 2014, she was diagnosed with idiopathic pulmonary arterial hypertension (IPAH), an extremely rare condition affecting roughly five per million each year.

This followed periods of rapidly progressive breathlessness and blackouts, while Mrs Jones was also said to have had significantly mobility issues related to rheumatoid arthritis.

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She had received specialist care at the Royal Hallamshire Hospital in Sheffield for her IPAH, and was said to have been managing her condition well, with the help of her husband, David.

But on the night of August 17, 2018, Mrs Jones had been staying with her sister in Llandudno, as she had many times before, spending the evening having a Chinese takeaway and sharing a bottle of wine, after which they fell asleep.

At approximately 1am on August 18, Mrs Jones went to walk upstairs before likely falling down the entire flight.

Dr Rachel Limbrey, consultant in respiratory medicine and a lecturer at the University of Southampton, filed a report on the events surrounding Mrs Jones’ death.

She said that, while her chances of survival after the fall would have been slim regardless due to her health conditions, the delays to an ambulance arriving for Mrs Jones “set the tone for the events which followed”.

Mrs Jones was said to have resisted attempts from paramedics to formally immobilise her upon their arrival but, it seemed, “she was never really comfortable”.

Glan Clwyd Hospital, Bodelwyddan (Image: Newsquest)

And while Dr Limbrey said it would have been inappropriate for staff to force immobilisation, she took issue with the impression given that Mrs Jones was “intoxicated”, and the fact that she was admitted to Ysbyty Glan Clwyd’s minor injuries unit.

She said: “It seems lots of the delays were because she was presented to the (Glan Clwyd) Emergency Department (ED) as a lady who had drunk too much alcohol and had a drunken fall.

“It seems terribly unfair that that’s how it was presented, and it seems unlikely, as well.

“I’d have thought it would have been sensible that it had been treated like a significant trauma – then, of course, she would have gone into resuscitation services and been treated very differently.

“She went into minors, where she sat for hours before having an assessment. Everything just took such a long time.

“I felt she was just being pushed around a bit, without anyone taking any overarching responsibility.”

Mrs Jones had also recorded a raised temperature of 38.5°C while in hospital.

Regarding Mrs Jones’ treatment in Stoke, Dr Limbrey added: “I am just surprised she ended up being left in ED for such a long period of time, then more faffing about while they could not decide where to send her.

“Someone with this level of IPAH should, in my opinion, have been in a Level Two facility. It wouldn’t have crossed my mind to send her to a ward.”

Representing Betsi Cadwaladr University Health Board (BCUHB) and the Welsh Ambulance Service (WAS), Daniel Rogers said that, at the time, Glan Clwyd’s minors unit was essentially running as an extension of its major injuries department.

Keith Dorrington, clinical lead at WAS, said the service has “made some significant changes” to how it operates since Mrs Jones’ death.

Among these is the access it now has to “Consultant Connect”, a telemedicine provider transforming patient care in the NHS through better communications.

Coroner's Court, Ruthin (Image: GoogleMaps)

Mr Dorrington said: “We’ve already held our hands up that pre-alert was not used on this occasion.”

And while he accepted that ambulance waiting times remain challenging, he added: “hospitals are doing all they reasonably can to maintain the flow.”

But, he said, there is an “overreliance on the ambulance service to be the solver of all problems”.

He added: “In my experience, I’ve never had a doctor speak to me inappropriately about pre-alerts.”

Dr Tom O’Driscoll, consultant in emergency medicine and clinical director of emergency care at Glan Clwyd, and Mr Balasundaram Ramesh, medical director at the hospital, also gave evidence at today’s inquest.

Dr O’Driscoll said the Dr Limbrey’s report was, “in part”, a fair assessment.

He added: “When our department opened its new building in 2014, the minors area was very much intended to be for classic minor injuries.

“Pretty much within the space of a few weeks, it became apparent that we were never going to be able to use it in that way, because of the volume of majors.”

Though, Dr O’Driscoll accepted that, “on reflection, resus might have been more appropriate” for Mrs Jones.

Asked whether pressure on the department played a role in Mrs Jones’ case, Dr O’Driscoll said: “I think it will have done.”

He said that, if Glan Clwyd was managing Mrs Jones today, he would intend for her to be in resuscitation services, and that the hospital now has better communication with the Royal Stoke University Hospital.

In conclusion, he said, the same course of events is now less likely to re-occur.

Mr Ramesh, when asked if it was time to rename the areas of the hospital in question due to patient perception, said: “This is going to happen.”

He also admitted that engagement with Mrs Jones’ family was not as high a consideration as it perhaps should have been.

Mr Gittins returned a medical cause of death of right ventricular hypertrophy due to IPAH and traumatic injuries as a result of a fall.

He said that there was a “lack of overall control by a single clinician” and the progress was “slower than might have been reasonably expected” in Mrs Jones’ case, who remained on a hospital trolley in the meantime.

“Neither health board may have covered themselves in glory in the provision of care and treatment of Mrs Jones,” Mr Gittins added.

But, he said, “this was not causative of her death, and it’s unlikely that the trauma of her fall and injuries would have been survivable, in light of her existing cardiovascular illnesses.”

Following Mr Gittins’ ruling, Mrs Jones’ son, Vince, gave a statement.

Mr Jones said: “From the moment the paramedics came to help our mum, having had a fall at her sister’s home, to the moment she passed away after nearly three days lying flat on her back in a hospital bed where she eventually passed away, we feel she was failed at every level and not given the very basic of care and treatment that she or anyone else would expect or deserve.

“The internal investigation by BCUHB identified 10 breaches of duty in her care, and the report stated: ‘It is clear that harm may have been caused as a result of the breaches of duty’.

“An independent medical expert (Dr Limbrey)’s report said in summary that: 'In my view, the care afforded to Mrs Jones right from the outset including that delivered by the paramedic crew, the triaging professionals at Glan Clwyd, and the medical assessments, along with the squabbling between teams, was abject.

“In the report, the medical expert was particularly struck by the high pain score and deterioration throughout her stay in Glan Clwyd.

“The concern and deterioration in mum’s condition was ignored and disregarded throughout, despite the family constantly challenging and alerting the staff.

“The report also stated: 'This is wholly unacceptable in a modern-day, first world medical facility’, with which we agree whole-heartedly. 

“We thank the coroner for his narrative verdict today, and just hope that BCUHB do stick by their word and show a drastic improvement in the basic care and compassion that anyone in this modern world deserves.”