Coroner ‘astounded’ at hospital’s care of late Llandudno Junction man

Steven Davies, 50, of Marl Drive, was taken by ambulance to the Bodelwyddan hospital’s emergency department early on April 26, 2022, complaining of chest pains.

He was discharged at 1.20pm that day, telling his brother that he believed he had trapped wind.

Mr Davies was then found unresponsive by his mother, Erica, at their home early on May 10, 2022.

Following a full inquest into Mr Davies’ death, held in Ruthin on June 7, Elizabeth Dudley-Jones, assistant coroner for North Wales East and Central, today (June 9) recorded a narrative conclusion.

Ms Dudley-Jones gave a medical cause of death of acute heart failure, contributed to by coronary artery atheroma and thrombosis.

She also referred Dr Tom Burton, who saw to Mr Davies at Glan Clwyd on April 26, to the General Medical Council, having been left “very concerned” by his actions.

Steven Davies and his late father, Joseph (Image: Family handout)

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Born in St Asaph, Mr Davies did not marry and was his mother’s carer at the time of his death, having previously also cared for his late father, Joseph.

A statement from one of his three siblings, David, read that he struggled with weight issues and suffered from Type 2 diabetes, high blood pressure and depression.

It was his family’s concern that his “premature” death could have been avoided had he received different treatment at Glan Clwyd on April 26.

On the day in question, he underwent no blood tests, nor was he referred to the hospital’s cardiology department.

Following his discharge, Mr Davies was still suffering from the same symptoms, and was advised by his GP to return to hospital but refused to, fearing being a “time-waster”.

Dr Burton was working as a locum consultant in emergency medicine at the hospital when he saw to Mr Davies.

He said Mr Davies had felt “crushing chest pains” since 11.45pm on April 25, but was pain-free when he arrived at Glan Clwyd.

After first seeing Mr Davies at about 12.55pm on April 26, Dr Burton made notes on “Symphony”, a digital system used to monitor patients.

Dr Burton deemed Mr Davies’ pulse to be regular and his chest clear, saying that he showed “no signs of a heart attack or poor blood supply”.

He recorded that Mr Davies was possibly suffering from ischaemic chest pain, before diagnosing him with costochondritis – the inflammation of the cartilage joining the ribs to the breastbone.

In hindsight, he said, he “possibly could and should” have recorded a diagnosis of gastro-oesophageal reflux disease (GORD - where stomach acid leaks up into the oesophagus) instead.

“I believe I should have spent more time thinking about his risks,” Dr Burton said.

“Mr Davies hadn’t had a heart attack then, but by virtue of his background factors and the way he presented himself, he was likely to be at risk going forward of having a significant event such as a heart attack.

“Frankly, I regret that I didn’t (spend more time considering Mr Davies' risks) at that point.”

Ysbyty Glan Clwyd, Bodelwyddan (Image: Newsquest)

As a locum doctor, Dr Burton had not worked at Glan Clwyd for three months prior to this “sad incident”, and was, by his own admission, “not familiar” with various clinical guidelines at the hospital.

That Dr Burton erroneously recorded Mr Davies’ raised levels of troponin, a marker of cardiac injury, was attributed to time pressures and his lack of familiarity with the digital system.

He conceded that the notes he recorded about Mr Davies contained uncorrected errors, and were briefer than usual.

April 26 was, he said, “harder than the average day” in emergency medicine, with Dr Burton adding that the system had been introduced since his previous visit to Glan Clwyd.

Asked if he approached Mr Davies in a “hurried” manner, he answered: “Absolutely not.”

Dr Burton said: “I’m very sorry that he went away with the impression that he was wasting people’s time. I don’t consider any A&E patient to be wasting my time, ever.

“The pressure of time and workloads may have impacted on my documentation, but I never let it impact on the human interaction. I’d be very disappointed in myself if that were the case.

“I should have been cognizant of this gentleman’s risks going forward, and I wish that I’d acted on that.

“I wrote nothing about my usual obsession, which is safety-netting. That suggests to me that I was working under stress, and trying to work too quickly.”

Though Dr Burton said he received an induction during his first period at Glan Clwyd (October 2021 - January 2022), this did not transpire when he returned in April.

On why he did not make himself aware of the hospital’s clinical guidelines before returning, he said: “There’s an enormous number of guidelines; an enormous amount to do.

“This was either my first or second day (back) at Glan Clwyd. With the best will in the world, I could not have gone through every guideline in a 24-hour period of time.”

Addressing Mr Davies’ relatives, Dr Burton said: “I feel very sorry for their loss of Steven, particularly as they closely experienced what happened a few days later.

“It’s very, very sad. I feel very sorry for him, and for them.”

County Hall, Ruthin (Image: Newsquest)

Matthew Cooper, a paramedic, attended Mr Davies’ home following an emergency call made at about 7am on May 10.

He said that Mr Davies was found unresponsive by his mother on their couch that morning, having been unwell for a period of time prior to then.

Mr Davies was pronounced dead at 7.35am on May 10.

Dr Muhammad Aslam, in undertaking Mr Davies’ post-mortem examination, found a “heavy heart” and “features of severe coronary artery atheroma and thrombosis”.

This, he recorded, had led to acute heart failure, and as such, he provided a provisional cause of death of natural causes.

Following a subsequent investigation and review, Dr Tom O’Driscoll, consultant in emergency medicine and clinical director of emergency care at Glan Clwyd, said he is now more confident that all new staff members are inducted thoroughly.

He accepted “pathways were not followed” in Mr Davies’ case, but believes appropriate changes have since been made to diminish the likelihood of this re-occurring.

Dr O’Driscoll said: “He was within reach of a specialist team who were in a good position to assess and support him.

“In my view, there was an opportunity to do that for him, whether as an outpatient or inpatient, and I apologise on that basis.”

Concluding, Ms Dudley-Jones said there had been “serious failures” in the care given to Mr Davies, which had “probably contributed” to his death.

She said that Dr Burton’s consultation with him was likely “rushed” and “dismissive”.

Ms Dudley-Jones said: “The risk factors should have been abundantly obvious. Just looking at Steven would have revealed the top three risk factors identified by Dr Burton.

“I’m frankly astounded that Dr Burton didn’t spend more time thinking about the obvious risks.

“Steven’s patient journey was nothing short of shocking.”

Ms Dudley-Jones added that Mr Davies’ impression that he would be considered a “time-waster” if he were to re-contact the ambulance services “has come from somewhere”.

She added: “I find that Dr Burton’s consultation was rushed and dismissive, and gave the impression to Steven that there was not much wrong with him.

“Although he was a locum, he nevertheless should have discussed Steven with the cardiology team.

“Steven’s death would likely have been avoided if he had been provided with a referral for cardiology assessment and appropriate intervention.

“I do welcome the fact that there is trust-wide learning from this incident, and the serious approach that the trust has taken to induction and access to care pathways.”

Following the inquest’s conclusion, Mr Davies’ brother, David, gave a statement on behalf of his family.

He said: “I would like to pay tribute to my late brother, who was my disabled mother’s carer.

“The family are still in shock after hearing the details of the failures in his care during his visit to Glan Clwyd.

“We take comfort from the changes Glan Clwyd have put in place since my brother’s death, and hope that other families may be spared the tragic loss we have suffered.

“We would like to thank The Coroner’s Office, especially Ms Dudley-Jones, for combining their thorough investigations with compassion for the family.”