THERE WERE failures and missed opportunities in the treatment of an Abergele farmer before his death at Ysbyty Glan Clwyd, an inquest has heard.

Robert Emlyn Williams, of Llethr, Gwytherin, died aged 75 at the Bodelwyddan hospital on October 29, 2022.

After concluding the inquest into his death on April 10, Kate Robertson, assistant senior coroner for North Wales East and Central, said she would defer a decision on issuing a Prevention of Future Deaths (PFD) report to the health board regarding the communication of blood results.

The inquest heard that, on October 27, 2022, Mr Williams had had a “busy morning”, helping on his farm and attending church.

That afternoon, he mentioned feeling pain and said this was likely to do with gall bladder and gall stones, for which he had had a removal procedure after complaining of “unbearable pain” on a trip to a caravan site near Aberystwyth.

At the time, he had been told he would be monitored and would be informed about getting his gall bladder removed and that he would be given a future appointment - this never happened.

Mr Williams, who had been diagnosed with multiple sclerosis in the 1970s, later complained of pain in his chest which was “not getting better”, his daughter Glesni Driver told the inquest.

At around 9.35pm, he said he felt pain down both his arms as well as his chest, with the family told that an ambulance could take five hours to arrive.

Therefore, he was taken to Ysbyty Glan Clwyd by his family, making it in “good time”, with Mr Williams fluctuating between moments of pain and comfort.

They arrived at the hospital just after 11pm, with Mrs Driver “very surprised” to see no ambulances in the bay, and nobody waiting to be booked in or queueing.

Mrs Driver, who works for the health board, said the hospital had been “much busier in the past”.

They were told that an electrocardiogram (ECG) was needed, to monitor Mr Williams’ heart rhythm, with results likely returning within an hour.

He was attended to by Dr Seramanperuman Sivaraman, with this "vital" step being done as quickly as possible given his chest pain.

Dr Tom O’Driscoll, consultant in emergency medicine at Ysbyty Glan Clwyd, said the ECG was taken and reviewed by a doctor, but not timed, with the time period between events and entries on that night “possibly too long”.

Tests showed Mr Williams’ troponin level, a protein found in the heart muscle, was at 28, which although elevated, was not at a level that would concern medical staff.


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This level of troponin would not have been flagged by laboratory staff to the ED via a phone call.

Although the ECG had showed blood rhythm was “not normal”, it would result in the administration of blood thinners and medicine including aspirin.

He was soon lead (walking) to the ‘majors’ unit for further monitoring, with the clinician adding he would need another ECG within 30 minutes to monitor Mr Williams’ progress.

This was not done, but Dr Paul Kumar Das, an interventional cardiologist at Ysbyty Glan Clwyd, said that although another ECG would be expected within an hour of the first, it was “unlikely” this would have changed the treatment “to a major degree”.

When in majors, Mr Williams was at first in the corridor, without a bed, which Dr O’Driscoll told the inquest was “poor patient performance” but “unfortunately an extremely common occurrence”.

Staff did not seem concerned for him, his daughter said, which was “a comfort to the family”, and Mr Williams was monitored.

Mrs Driver said the unit appeared “quiet”, with staff checking his vitals every so often, but with his waves of pain now “quite strong”.

After 3am, on October 28, he began “groaning” and his face went a “different colour”, he began jolting backwards, and had a “massive” heart attack.

Medical staff successfully performed CPR, with the lack of oxygen leading to organ and brain damage.

He underwent a stent operation, where four stents were put in a main artery – “highly unusual” as normally only one or two are put in.

Mr Williams was moved to a critical care unit, with his family told he was now “very ill”, with his blood pressure dropping.

He again went into cardiac arrest, with another round of CPR stopped with a life support machine now “doing all the work”.

At around 6.45am on October 29, the family were told his condition had deteriorated, with nothing more to be done as his blood pressure continued to drop.

The nurse then said he had passed away, within minutes of his family being there.

A medical cause of death was given as acute myocardial infarction (heart attack) due to cardiovascular atheroma and contributed by pulmonary disease.

Betsi Cadwaladr University Health Board, in a statement, “accepted missed opportunities and failures in the care for Mr Williams”.

Mrs Robertson said Mr Williams’ expressed bouts of pain were “not adequately acted upon”, with the result from the ECG “not shared” with attending medical staff.

She added that she was “pleased” there had been “learning and change” as a result of Mr Williams’ death.

Recording a narrative conclusion, Mrs Robertson said: “Robert Emlyn Williams died on October 9 2022 at Ysbyty Glan Clwyd from naturally occurring medical conditions where timely and adequate care and treatment in the Emergency Department may have prompted further investigations allowing for potentially life-extending treatment.”

Addressing the family, she said: “My sincerest condolences to you as a family.

“I hope that in time you take some comfort in the issues that have been addressed here.

“The dignity you have shown by offering to share your experiences shows how difficult it must have been.”

The health board will be given 28 days to respond to Mrs Robertson about its efforts to introduce a process or procedure of the sharing of blood results, and what is being done to address the issue.