A MAN from Deganwy who died after suffering a fall at his home was left unable to move for approximately 12 hours while he waited for paramedics to arrive, an inquest heard.

Robert Anthony Dewhurst died aged 87 in the early hours of March 17, 2022 at Ysbyty Glan Clwyd, Bodelwyddan.

At a full inquest into his death, held in Ruthin today (July 21), John Gittins, senior coroner for North Wales East and Central, gave a narrative conclusion.

Mr Gittins provided a medical cause of death of sepsis and rhabdomyolysis, contributed to by ischemia of the left leg, systemic atherosclerotic disease, and ischemic hypertensive and chronic valvular disease.

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The inquest heard that, at about 9.30pm on March 15, Mr Dewhurst suffered a fall in the upstairs bathroom at his home on Deganwy Quay, rendering him unable to move.

He was left wedged between his toilet, bath and bathroom wall, and it was not until about 9.30am the next morning that paramedics began to arrive despite five emergency phone calls being made.

Sally Cureton, Mr Dewhurst’s daughter, arrived at her parents’ home early on March 16, and was “shocked” to find his left leg blue in colour.

Mrs Cureton said emergency calls were not given priority given Mr Dewhurst, a retired clothing manufacturer, was considered a “frequent faller”.

After Mr Dewhurst had been on the floor for approximately 12 hours, the Welsh Ambulance Service Trust (WAST) sent a paramedic from St John Ambulance to attend his home.

“Our family firmly believe he would still be alive now had an ambulance come within the appropriate time scale,” Mrs Cureton said.

Mike Williams, an urgent care/falls assistant for St John Ambulance, requested additional support to lift Mr Dewhurst after arriving at his home.

WAST staff attended the scene roughly 20 minutes later, and Mr Dewhurst was then supported and lifted on to his toilet.

Though, it was apparent that his left leg needed treatment under hospital care urgently.

Mr Dewhurst was carried downstairs on a chair, before being assisted on to a stretcher, and then transferred to Ysbyty Gwynedd, Bangor, arriving at 12.10pm.

He was initially taken to Ysbyty Gwynedd due to too many ambulances at Glan Clwyd waiting to offload patients.

But upon arrival at the Bangor hospital, paramedics were asked that he wait in the ambulance initially due to there being no space for him in its emergency department.

It later transpired that his left leg had had its blood supply compromised to such an extent, due to the length of time he had spent on his bathroom floor, that it needed amputating.

This could not take place at Ysbyty Gwynedd as there was not a vascular surgeon at the hospital able to perform the operation.

Mr Dewhurst’s wife, Beryl, said her late husband suffered “three or four previous falls”, but was “determined that there was nothing wrong with him”.

Nikki Sommers, emergency medicine consultant at Ysbyty Gwynedd, said Mr Dewhurst was seen to shortly after 12.30pm on March 16, registering a raised respiratory rate and a cold temperature of 35.2°C.

After his left leg was deemed unable to be salvaged and needing amputation, Mr Dewhurst was reviewed at about 7pm, when he was considered stable enough to be transferred to Glan Clwyd.

The transfer took place at about 9.30pm on March 16, with Mr Dewhurst arriving at the Bodelwyddan hospital at 10.22pm.

A senior house officer on call overnight for general surgery at Glan Clwyd said that, shortly after midnight on March 17, nursing staff were unconcerned their observations of Mr Dewhurst.

He appeared stable, so the hospital’s “more unwell patients” had to be prioritised.

But as Mr Dewhurst’s condition worsened, with him later becoming unresponsive, the conclusion was reached that he was dying imminently, and he was then prescribed end-of-life medication.

His death was verified at 5.35am on March 17.

Karen Grimshaw, a matron, was on a secondment with Glan Clwyd’s vascular team at the time of Mr Dewhurst’s death.

She recalled the evening of March 16, when he was transferred to the hospital, being “particularly busy”.

Indeed, she said an “extraordinary meeting” was held among staff due to the long ambulance waits outside the site, and the hospital being full to capacity.

Gill Pleming, a service manager with WAST, said four of the five emergency calls regarding Mr Dewhurst were coded as “Green 3” – meaning an ambulance would likely take between seven to eight hours to arrive.

Pressures on the organisation at the time were, she said, “quite significant,” with more than 20 people ahead of him waiting for an emergency ambulance.

The length of time which Mr Dewhurst’s transfers took, both to Ysbyty Gwynedd and later to Glan Clwyd, “doesn’t make for good reading,” Mr Gittins said.

Indeed, Ms Pleming admitted this was “not the service we want to provide to our patients”.

Steven Williams, interim service manager for North Wales for the emergency medicine aspect of WAST, said steps have been made to help reduce the chance of a similar incident re-occurring.

Among those measures, he said, is a new “vascular pathway”, introduced last December, whereby staff can make contact with a senior-grade clinician who can provide them with specialist advice.

Dr Tom Davis, medical director at Betsi Cadwaladr University Health Board, said the organisation has conducted its own investigation into the circumstances surrounding Mr Dewhurst’s death.

“While we recognise that there’s still a lot to do, we have made significant progress (in ensuring patients receive appropriate treatment sooner),” he said.

In undertaking Mr Dewhurst’s post-mortem examination, Dr Muhammad Aslam found his heart was “extremely heavy”.

There were also signs that he had suffered left ventricular hypertrophy, as well as a “very high level” of inflammatory markers indicating sepsis and rhabdomyolysis (a condition which occurs when damaged muscle tissue releases its proteins and electrolytes into the blood).

Mr Dewhurst also suffered from heart disease, but the reduced blood flow in his left leg was the more likely cause of his sepsis and rhabdomyolysis, Dr Aslam said.

Concluding, Mr Gittins “entirely accepted” that there continue to be significant challenges in the availability and provision of emergency ambulances.

He refrained from issuing a Prevention of Future Death Reports, but asked for further evidence of an “action plan” from the health board within 28 days.

To representatives from WAST and the health board in attendance, Mr Gittins said: “The challenges you undoubtedly face are unprecedented, and I’m confident you’re doing your best in facing them.”

Offering his condolences, Mr Gittins told Mrs Dewhurst: “Despite what we have today and in March of last year, you have a lifetime of memories to keep you going.”