Standby emergency team wasn't called to help Rhyl woman, inquest hears

Vivienne Greener, who taught at Ysgol Mair in Rhyl for 30 years, died at Ysbyty Glan Clwyd, Bodelwyddan on March 20, 2018 aged 64.

A provisional cause of death for Mrs Greener has been given as multi-organ failure due to sepsis.

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Patients ‘beg’ not to go to Ysbyty Glan Clwyd, inquest hears

During today’s (December 14) hearing in Ruthin, Balasundaram Ramesh, medical director at Glan Clwyd, said this team could have been called urgently to assist, but that its services were, for whatever reason, not utilised to assist Mrs Greener.

David Pojur, senior coroner for North Wales East and Central, also called the quality of some of the received witness statements from Betsi Cadwaladr University Health Board in relation to Mrs Greener’s death “inadequate”.

After a four-day inquest, Mr Pojur was due to record Mrs Greener’s medical cause of death and a conclusion of the inquest today, but he will now do so on December 18.

He said: “It seems to me there is a reluctance of the people who have produced documents not wanting to come and give evidence (in person)… I think that’s a problem.

“The quality of witness statements from the health board is inadequate.

“There seems to be no quality control; there seems to be a view that, the less a witness says, the more chance they’ve got of not being required to give evidence. I can say that the reverse is true.”

Ysbyty Glan Clwyd, Bodelwyddan (Image: BCUHB)

The inquest had previously heard that Mrs Greener was admitted to hospital shortly after midnight on March 20 after coughing up blood.

But despite it transpiring that she required an endoscopy – a procedure to look inside a patient’s body – this was found to be unavailable anywhere in North Wales at that time of night.

Due to lack of availability, Mrs Greener was not transferred from the ambulance into hospital until roughly hour after arriving at Glan Clwyd, during which time she lost more blood.

It was also heard that Mrs Greener’s condition was not escalated to the appropriate level, and that doctors did not do enough to help her.

Dr Eve Blakemore, acting medical registrar on the night, had told the inquest that she had been called by junior staff nurse Zoe Mahmood to “come now” because she felt Mrs Greener “wasn’t getting the input and treatment” necessary from her colleague, Dr Chukwuemeka Nwaneri.

She added that senior anaesthetic registrar, Dr Syed Raza, later attended and felt Mrs Greener did not require intensive care input.

In addition, Dr Blakemore told the inquest that she and Ms Mahmood were “very angry” that help did not arrive promptly, given Mrs Greener was visibly distressed.

During today’s hearing, the inquest heard from Duncan Robertson, assistant director for clinical development at the Welsh Ambulance Services Trust.

While a “pre-alert” was not made by paramedics in Mrs Greener’s case before she arrived at Glan Clwyd, Mr Robertson accepted that, in hindsight, this could have been beneficial.

Now, all clinical staff are issued with iPads, he said, with a specific application where clinical notes can be posted, so that they don’t have to “commit to memory” key information.

Mr Robertson’s colleagues had previously told the inquest that they had pressed for Mrs Greener to be admitted to Glan Clwyd, which he said was “absolutely correct”.

At that stage, he added, “I think it’s hard to know what else they could have done”.

“The health board has made a problem for you, hasn’t it?”, Mr Pojur asked him.

“The job of the ambulance service is manifestly not sitting outside hospitals.”

Mr Robertson added that senior clinicians are now available at all times so that, if staff have questions such as whether to issue a pre-alert, they can contact them for advice.

Meanwhile, Mr Ramesh said there has been “important learning for everyone” from Mrs Greener’s case.

He added: “I’m saddened that, in this particular case, nothing was done in her ‘golden hour’ (the period immediately after a traumatic injury during which there is the highest likelihood that prompt medical and surgical treatment will prevent death).”

Perhaps, he said, staff “did not realise the seriousness of the problem”, such as by suggesting that Mrs Greener did not require intensive care treatment, thus giving the sense of a “non-emergency”.

Asked if an out-of-hours endoscopy would be more readily available at Glan Clwyd now, Mr Ramesh said there is still a “mismatch” regarding the supply and demand of the procedure.

While a newly qualified endoscopist has been recruited, they are not due to start at Glan Clwyd until February, and another “six or seven” would be needed before achieving out-of-hours availability.

Dr Nwaneri, while giving evidence, recalled a “chaotic environment” at the hospital that night, a common state of affairs which “never improved at all” up to his departure in 2019.

He added that he “totally disagreed” with Dr Blakemore’s version of events, in which she claimed she was essentially left alone with Mrs Greener.

“We never, ever totally leave colleagues if they are struggling,” he said.

“If Eve needed, in any way, my assistance, she could have asked. We do not act in isolation in a case that needs urgent care.”

A confidential report compiled by the health board found that there was a “breach in duty of care” in Mrs Greener’s case.

The report also criticised not escalating Mrs Greener – when asked if he considered contacting an emergency department consultant, Dr Nwaneri replied: “My priority was to make sure the patient had the best care.”

Despite it transpiring that Mrs Greener may also have benefitted from a blood transfusion immediately upon her arrival at Glan Clwyd, this did not materialise.

Dr Nwaneri did not think she was sufficiently unwell to require this, adding that he was “not informed otherwise”.

The inquest will resume and end on December 18, when Mr Pojur gives his conclusions.