'Lessons' after death of man, 81

Eryl Hughes-Jones was at the doors to Llandudno Hospital before being turned away

A coroner has said lessons need to be learned after communication problems over a pensioner's condition as he was being rushed to hospital.

Eryl Hughes-Jones, 81, was just yards from a resuscitation unit at Llandudno hospital when paramedics treating him were ordered to divert to Glan Clwyd hospital.

He suffered a fatal heart attack en route and died 20 minutes later.

Coroner John Gittins recorded a verdict of death by natural causes.

The inquest at Llandudno heard paramedics Osian Roberts and Simon Hooton were called to the Treflys nursing home in Llandudno in June 2008 after Mr Hughes-Jones had apparently taken a fall.

Mr Roberts said he could see the retired health and safety officer was suffering from respiratory failure.

Respiratory failure

He decided he should be taken to Llandudno hospital because he believed that the patient was going to suffer cardiac failure.

It was explained at the inquest the hospital accepts patients with cardiac failure because it has a resuscitation unit.

But respiratory failure cases are taken to either Glan Clwyd in Bodelwyddan or Ysbyty Gywnedd in Bangor.

The coroner was told that in the rush Mr Hooton reported the case to ambulance control as a respiratory failure case.

He was asked by the coroner what he would have done differently with hindsight.

"I'd give a more thorough alert to control," said Mr Hooton.

He was transferred to Glan Clwyd Hospital, but died soon after arriving

The inquest heard recordings of conversations between ambulance control and staff at Llandudno.

In the recording, nurse Christina Bowen is heard insisting that they cannot deal with respiratory cases because they do not have an anaesthetist at the hospital.

Ambulance control then inform her that the patient is going into cardiac failure and asks if a doctor can go outside to look at the patient.

Ms Bowen insists the hospital cannot deal with respiratory cases and says that the ambulance has got equipment used for ventilating patients which they did not have.

In her evidence, the nurse said that a locum doctor, who did not attend the hearing, took the call initially but then passed it to her.

"The only information I got was that it was a respiratory arrest. I was trying to explain to them that we don't take them," she said.

Blood clots

The coroner asked Ms Bowen why the doctor had not gone to look at Mr Hughes Jones when the ambulance arrived, no matter what the protocols were.

"He could have got up and walked out to the ambulance," said Mr Gittins.

"I suppose so," replied the nurse.

The ambulance then went to Glan Clwyd and the pensioner suffered a cardiac arrest en route, and died 20 minutes after arriving.

The inquest heard that Mr Hughes-Jones died as a result of blood clots spreading to his lungs.

The coroner said he may well have died anyway but he asked anaesthetist Dr Anthony Shambrook if his statistical chances have improved if he had been treated in Llandudno.

"In these particular circumstances I would say yes," said Dr Shambrook.

The coroner said all the staff were trying to do their best and work to protocols and rules.

Unfortunately, he said, "working to the rules and not taking the extra step" meant the pensioner's chances of survival were reduced.

"I have every confidence in the (health) trust and the ambulance service that lessons will be learned," he said.