Rhyl pensioner vows to fight for the full facts behind his wife's death


Staff reporter (Rhyl Journal)

A PENSIONER has vowed to keep fighting for the full facts of how his wife died at a Rhyl nursing home.

A Protection of Vulnerable Adullts (PoVA) inquiry was launched after Zam Mead complained to the Care and Social Services Inspectorate for Wales about the circumstances leading to his wife’s death in February this year.

Barbara Mead, aged 78, died at Preswylfa Care Home two days after a percutaneous endoscopic gastrostostomy (PEG) which had been inserted into her stomach to feed her direct was somehow pulled out.

Doctors at Glan Clwyd Hospital, where the PEG had been fitted, advised that it could not be reconnected and so Mrs Mead returned to Preswylfa with an “end of pathway” plan.

The investigation team found no “wilful act of neglect” but Mr Mead, a former probation officer, of Rhuddlan Road, Rhyl, is not satisfied that the inquiry unearthed the full facts.
In February, 2012, Mrs Mead hit the headlines when, after suffering two strokes and a fall which left her unconscious, she was given just two days to live.

However, when her son Paul stroked her face as she lay in bed in Glan Clwyd Hospital, she regained consciousness and commented on his cold hands.

After leaving hospital she went to Preswylfa in June, 2012, where she remained and was fed through a nasal tube.

The tube kept getting blocked, however, and in January this year it was decided to fit a PEG.

Mrs Mead returned to the home on the 15th, her care plan stating that the insertion site had to be inspected daily. A nurse from the hospital visited the home to explain to staff what needed to be done.

Mr Mead said that the following day his wife looked a little better and on the 17th he was with her all afternoon until 5.30pm.

At 8.30pm, however, he was called to say that she was being taken back to hospital because the PEG had been pulled out. Too unwell for surgery, she was taken back to Preswylfa and died on February 7, having had no food or drink for over a week.

Mr Mead said he asked the then manager – a new manager is now in post – and was told “I don’t know, I wasn’t there.”

“The hospital told me that someone must have tugged it out but Barbara couldn’t have done it herself because she couldn’t move her arms,” said Mr Mead.

The CSSIW agreed to investigate and a PoVA inquiry was launched.

Mr Mead also contacted Vale of Clwyd MP Chris Ruane who, at his request, put four questions to Gwenda Thomas, the Welsh Government’s Deputy Minister for Social Services.

One of the questions was “Who attended to Mrs Mead to turn her over between 5pm and 8pm when the feeding tube was pulled from her stomach?”

Mrs Thomas replied: “CSSIW have advised me that they do not hold records of those staff directly supporting Mrs Mead between these hours”.

The PoVA report states that records show that on the day the incident occurred checks had been carried out at 2pm and at 5pm when feed was inserted in the tube. The alarm was raised at 8.30pm

In statements to the inquiry staff said that Mrs Mead, whose limbs were “contracted”, had pulled the tube, catching it when being repositioned.

In conclusion, the investigation panel found that staff had followed the correct procedures and had received training in the management of the PEG and in manual handling.

“We did not find any wilful act of neglect,” they stated.

But Mr Mead, who praised NHS staff for their care of his wife, said: “I have never accused anyone of wilful neglect but that does not mean that neglect did not occur.
“I don’t accept the evidence given and still want to know what happened in those three hours. I am going to pursue this through other channels,” he said.

A spokeswoman for the home, which is part of the nationwide Embrace Group, stated: “The health and wellbeing of the people we support is our number one priority and we always take relatives’ concerns very seriously.

“When Mrs Mead’s husband expressed concern about her care after she passed away in February we carried out a thorough investigation. Detailed investigations were also carried out by the relevant authorities. All of these investigations, both internal and independent, concluded that there had been no failures in Mrs Mead’s care. Our thoughts remain with Mrs Mead’s family at this difficult time.”

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