AN ELDERLY woman's death followed a number of failures by a hospital, an inquest heard.

Phyllis France, who had been living at The Nash residential home in Churton Road, Rhyl, died at Glan Clwyd Hospital on March 2 last year. She was 76.

A resumed inquest in Mold last week heard how she had been admitted to the hospital on February 17 after taking ill.

The cause of her death was determined by a post mortem examination to be bronchopneumonia and congestive cardiac failure due to arterial atheroma (hardening of the arteries) and infected leg and buttock ulcerations.

Mrs France's ulcers were naturally occurring as she had peripheral arterial disease, the inquest heard.

Joanne Lees, assistant coroner for North Wales east and central, said that what followed her arrival at the hospital was a series of failures.

An investigation report by Betsi Cadwaladr University Health Board identified these issues, including a delay in transferring her from the ambulance to the hospital, a failure to commence a wound chart on admission, a failure to provide an air mattress in the emergency department, a failure to complete documentation, a failure to make enquiries regarding a safeguarding referral, a failure to correctly grade a sore on handover and more.

The inquest heard how at some points Mrs France was also not repositioned enough - a practice referred to as rounding - in order to manage her pressure sores.

Mrs Lees told the inquest that the investigation report was "a clear acceptance of failure in care".

She also went on to read out a wide range of measures Betsi Cadwaladr University Health Board has put in place since the completion of the investigation.

Those include ensuring triage provision, especially when the hospital is under pressure, an area of pressure assessment to be implemented within one hour of arrival, an additional health care support worker to help with repositioning and rounding and a rapid assessment and treatment bay.

Steps have also been taken to ensure the availability of air mattresses and additional training has been given to staff for identifying and grading pressure sores.

There will also be audits undertaken to ensure rounding is completed and a review of handover documentation.

Mrs France's son James told the hearing: "They have done every procedure right to investigate.

"It's heartwarming to hear that. What we don't want to do is to overstretch the resources they do have.

"It should not have happened, but It did happen.

"It has been dealt with correctly, we know it is going to be monitored and that is all we can ask for."

Mrs Lees replied that the report and action plan put forward by the health board was "one of the most thorough" that she had ever seen.

She recorded a short narrative conclusion, telling the hearing: "Phyllis France died of the effects of an infection secondary to bronchopneumonia and congestive cardiac failure."

Mrs Lees added that she did not feel her duty to make a report for the prevention of future deaths arose, given the extensive list of actions taken by the health board following Mrs France's death.