BETSI Cadwaladr University Health Board has been handed a Prevention of Future Deaths (PFD) report after a teacher from Rhyl who died in 2018 was “failed” by its services.

Vivienne Greener, who taught at Ysgol Mair for 30 years, died at Ysbyty Glan Clwyd on March 20, 2018 aged 64 after coughing up blood earlier that night.

After a five-day inquest into her death, David Pojur, assistant coroner for North Wales East and Central, gave a narrative conclusion, before issuing a PFD report.

The inquest heard that a potentially lifesaving endoscopy was unavailable when Mrs Greener was admitted to hospital, and that a standby emergency team at Glan Clwyd was not called to aid her.

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‘Devoted’ Rhyl teacher was ‘failed’ by health board before her death

Mrs Greener’s medical cause of death was recorded as multi-organ failure, contributed to by massive upper gastrointestinal haemorrhage due to therapeutic use of Naproxen.

Mr Pojur also sent copies of the PFD report to the Department of Health and Social Care, the Welsh Ambulance Service, Clarence Medical Centre in Rhyl, the chief coroner, and Mrs Greener’s family.

In the report, he listed the following nine matters of concern:

  • An out-of-hours emergency endoscopy is still not available at Glan Clwyd or in this area of North Wales, as the provision has “collapsed” at Wrexham Maelor Hospital, so no referrals can be made.
  • There are insufficient doctors and nurses and space available to cope with the number of patients coming into the emergency department.
  • There is an ineffective triage and record of triage of patients arriving at Glan Clwyd emergency department by ambulance.
  • There is not a clear understanding of when the Emergency Treatment Team should be called.
  • There is not a clear understanding of when the Major Haemorrhage Pathway should be engaged.
  • The health board’s Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose.
  • Any learning from the Health Board’s investigation report is not adequately shared with its practitioners.
  • A part of the Health Board’s investigation report changed in different versions and obscured the reason why the provision of blood products was delayed meaning issues are not sufficiently identified and actioned.
  • Ambulances and paramedics are being kept at the emergency department as an extension of the hospital and its staff, due to the Welsh Ambulance Service being unable to get their patients admitted into the emergency department and back on active duty.

The health board is duty-bound to respond to the report by February 12, 2024, detailing action taken or proposed.

Otherwise, it must explain why no action has been planned.