Kinmel Bay man ‘berated’ by paramedics at Ysbyty Glan Clwyd

John Jesse Martindale, originally from the Doncaster area, died at the Bodelwyddan hospital aged 84 on October 28, 2013.

At a full inquest in Ruthin, John Gittins, senior coroner for North Wales East and Central, recorded a conclusion of death arising from natural causes.

Mr Gittins provided a medical cause of death of bronchopneumonia, contributed to by chronic obstructive pulmonary disease, coronary atheroma (heart disease), brain atrophy and agitation.

A statement provided by Mr Martindale’s son-in-law, Malcolm John Stewart, read that his father-in-law “always loved going out”, “loved his granddaughter and great grandson” and was “very sadly missed”.

Mr Martindale was born in Doncaster on April 25, 1929, and was a retired butcher.

The inquest heard Mr Martindale had a history of dementia, myocardial infarction, and atrial fibrillation (irregular heart rhythm).

Mr Stewart told the inquest that on October 23, 2013, Mr Martindale was transferred to Bay Court Residential Home in Kinmel Bay, adding that he was without his medication but seemed “content” and got on well with staff.

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At around midday on October 28, he was “lethargic”, largely slept, and was not responsive except for opening his eyes and closing them.

By this point, arrangements had been made for his medication, and he had registered with a GP.

Nursing home staff called for an ambulance at around 6pm that day, saying he was unwell with his chest.

Mr Stewart said Mr Martindale was soon taken into an ambulance with family members present, and upon arrival, noticed the ambulance was “rocking”.

He said a male paramedic asked Mr Martindale’s daughter Ann if she could calm him down, as he had become “agitated and aggressive”, and was being “extremely abusive” and was “scared to death”.

Mr Martindale emitted blood, defecated, and punched his son-in-law and spat at his daughter, Mr Stewart said.

During this time, Mr Stewart said one paramedic “stood with his hands in his pockets and did nothing”, “berated” Mr Martindale for his behaviour and shook his head, as the ambulance waited at the Emergency Department at the hospital to be booked in.

Barry Hughes, a Wales Ambulance Service emergency medical technician who was one of the paramedics who helped Mr Martindale, told the inquest he could not recall the incident.

The patient’s patient care report (PCR) stated he had been difficult to treat, and was distressed with this largely attributed to his confusion from dementia.

The family told the inquest that around 20 minutes later, he was then transferred by hospital staff, where his eyes rolled back, he began to spasm and doctors said he was “very poorly”.

While he struggled in hospital, the inquest heard that a passing nurse had told the family to “press the f****** button” for more urgent support.

He went into cardiac arrest, and after 45 minutes of resuscitation, the family was informed of his passing at approximately 7.40pm.

Mr Stewart said they had been left “traumatised”, adding that staff “did nothing to help at all, they let him and us down.”

A post-mortem examination was undertaken by Dr Andrew Dalton, consultant pathologist at Ysbyty Glan Clwyd, which found evidence of bronchopneumonia, chronic bronchitis, plural fibrosis, arterial atheroma, coronary artery disease, and enlargement of the prostate and shrinking of the brain (both likely age-related).

Concluding, Mr Gittins said the time since his death had made evidence-gathering more difficult.

He said: “Because of the time that had elapsed, it is very difficult to have a wealth of evidence.

“There is nothing before me to give me any reason to doubt the veracity of Mr Stewart, and the events given by Mr Stewart shape my conclusion.”

Mr Gittins gave a death arising from natural causes, with terminal bronchopneumonia, with contributing coronary airway disease, coronary atheroma, brain atrophy and agitation, which he said was “not inevitable” in death.

He added: My condolences to the family - I can never give families closure, but I hope that a degree of line drawing in terms of the legal matter of this has been given.”

What the Health Board said

Carol Shillabeer, interim CEO of Betsi Cadwaladr University Health Board, said: “I cannot imagine how difficult it has been for Mr Martindale's family and friends to wait for the length of time it has taken to reach a conclusion in this case.

“I want to offer my sincere condolences, on behalf of the Health Board, for their loss.”

What the Welsh Ambulance Service said

Liam Williams, executive director of quality and nursing at the Welsh Ambulance Service, said: “Our thoughts and condolences remain with Mr Martindale’s family through what has been and continues to be a difficult time. 

“We undertook a thorough investigation into Mr Martindale’s care at the time and offered a fulsome apology to his family for their poor experience. 

“I would like to offer our sincere apologies again today.

“We have made significant changes to the way we support our colleagues to care for people with dementia, including the appointment of a mental health and dementia care lead and additional training for our staff. 

“We have also worked closely with people with dementia to co-produce a communication guide to support care and are also trialling digital reminiscence therapy to further assist. 

“The Trust achieved recognition as a Dementia Friendly Community by the Alzheimer’s Society and this helps demonstrate our focus on improving inclusion and quality of life for people with dementia in all that we do.

“We would once again like to extend our sympathies to the Martindale family on their sad loss.”