A WOMAN from Corwen died after experiencing delays in her transfer from Wrexham Maelor Hospital to Ysbyty Glan Clwyd, Bodelwyddan for emergency surgery.

Maureen Elizabeth Owens, of Maesafallen Estate, died aged 79 at Glan Clwyd on December 9, 2022.

Following a full inquest into her death, held in Ruthin today (March 20), John Gittins, senior coroner for North Wales East and Central, recorded a narrative conclusion.

Ms Owens’ medical cause of death was noted as multi-organ failure, contributed to by bilateral femoral thrombosis due to underlying peripheral and central vascular disease.


Arrest made & police cordon in place after Prestatyn attempted robbery

Prestatyn florist closes immediately after ‘amazing six years’

The inquest heard that, on November 27, Ms Owens suffered a fall at home, causing injury to the left side of her head and rendering her “a little confused”.

She was taken by ambulance to Wrexham Maelor Hospital, and was transferred its stroke unit, the Bersham ward, the following day.

During her time in the hospital, her heart rate was “erratic”, fluctuating from “very low to very high”.

Her daughter, Jacqueline, said that, when she spoke to a doctor on November 30, she was “made to feel as though I was being a nuisance”, and was told that “she (Ms Owens) is not the only patient here”.

During the inquest, a legal representative for the health board apologised on behalf of the organisation for those comments, saying they were “wrong” and “shouldn’t have been said”.

Dr Walee Sayed, a stroke consultant at Wrexham Maelor, also apologised to Ms Owens’ family for her “bad experience” while on the Bersham ward, and said he had examined feedback received in her case.

On December 2, Ms Owens complained of cold feet to her family; nursing staff were informed, with nothing having been done to address this prior.

The following day, she again said her left foot was cold; a nurse was told about this and said it would be looked into, though Ms Owens’ daughter said “no-one came to see why her feet were cold” while she was there.

Her cold feet persisted the following day; again, nurses were told, but said they were “busy”.

Following a scan on December 6, Ms Owens was placed on blood-thinning medication, before it was agreed that she needed to be transferred via a blue-lit ambulance to Glan Clwyd.

A 999 call was made at 3.30pm that day, but the transfer did not happen until shortly after 4am on December 7; approximately 48 hours later, Ms Owens was pronounced deceased.

Dr Ashraf Elsharkawy, a consultant vascular surgeon, was working as a locum consultant for the health board at the time.

He advised that Ms Owen be transferred immediately to Glan Clwyd on December 6 due to her having blood clots on her legs, and described her situation as “very critical”.

Having expected Ms Owens to have undergone her operation overnight, he said he was “surprised” to find that she had only arrived at Glan Clwyd the following morning.

Regarding the delays in transferring Ms Owens from Wrexham Maelor to Glan Clwyd, he said: “I have to be honest, I haven’t seen that delay (previously).”

Ms Owens’ family placed on record their thanks to Dr Elsharkawy and his colleagues at Glan Clwyd who had tried to save her life.

Gill Pleming, service manager at the Welsh Ambulance Services Trust, said it was not until 3.26am on December 7 – roughly 12 hours after the initial 999 call was made – that an emergency ambulance became available to transfer Ms Owens.

By then, the call had been escalated to an “Amber One” category (life-threatening; response with lights and sirens).

She added that the service was operating at “level three” (severe demand) at the time, with roughly 25 “Amber One” calls ahead of Ms Owens.

Richard Waterson, a senior nurse at Wrexham Maelor, led the health board’s own internal investigation into Ms Owens’ case.

While he found that concerns about her legs were not formally raised until December 4, he said: “We can only apologise if that was not picked up sooner.”

He added that the health board is working with the ambulance service to “improve the pathway” by reducing delays, reviewing handover processes, and improving ambulance availability and patient flow.

Dr Andrew Foulkes, the health board’s secondary care medical director for the central area of North Wales, said it uses the Adult Critical Care Transfer Services (ACCTS) to assist patients such as Ms Owens.

This was running on a 24/7 basis at the time of her death, but while that is no longer the case, he said work is ongoing within the health board to look to return to this.

Concluding, Mr Gittins said he was “significantly concerned” that an immediate transfer between hospitals was not possible for Ms Owens.

While he found that her death arose from natural causes, he found that the operational delays meant she was not afforded the “timely care and treatment which may have optimised prospects of a full recovery”.

Though, he added: “I recognise that the challenges around the provision of the ambulance service across the entire country, let alone North Wales, are very much multi-factorial.”