Page last updated at 10:10 GMT, Thursday, 4 June 2009 11:10 UK

Fatal op mistake apology demand

Myron Hall
Myron Hall died after a breathing tube was incorrectly inserted

An NHS trust has been ordered to say sorry to relatives of a man who bled to death after a mistake during surgery.

A public services ombudsman report criticises the former North Glamorgan Trust saying staff actions resulted in the death of Myron Hall, 47.

Its successor trust, Cwm Taf, was asked to apologise personally but refused, saying it would write to his parents instead after the 2007 incident.

Mr Hall's parents also want police to look at possible criminal charges.

Denzil and Janet Tilley, of Porthcawl, arrived at the hospital seconds before their son died. In the report, the family compared the scene to a "horror movie".

Mrs Tilley told the South Wales Echo she could not get over what happened, and could not get the distressing sight of her son out of her head.

She added: "We did nothing but complain to medical staff. We knew something was wrong and Myron was trying to tell them but nobody listened, they just let my beautiful son die.

Ombudsman Peter Tyndall
... both the chair and the chief executive of Cwm Taf trust should provide [Mr Hall's] parents with an unequivocal apology for the failings that occurred...
Peter Tyndall, ombudsman

"All we want now is justice for Myron."

Mr Tilley added: "We kept telling the staff but they said that was the natural feeling he would get following the procedure. We knew our son, we knew it wasn't right."

Ombudsman Peter Tyndall stated he was concerned about the trust's ability to carry out ear, nose and throat (ENT) cancer treatment unless it made changes.

The former North Glamorgan is now joined with Pontypridd & Rhondda and is called Cwm Taf NHS Trust which manages the Royal Glamorgan Hospital in Llantrisant, and Prince Charles Hospital in Merthyr.

"I have major concerns about the ability of Cwm Taf trust to deliver ENT cancer services to patients unless significant changes are made," said Mr Tyndall.

"I have made a number of recommendations to the trust, which include changes to medical and nursing practices, training and operational procedures."

Mr Hall, an electrician from Bargoed, was referred to the former North Glamorgan NHS Trust in September 2006 by his GP because of a suspicious lump in his neck.

It took three months to diagnose a malignant tumour and doctors decided the best way to treat him was to remove half his tongue.

A tracheostomy tube was put in his windpipe to help him breathe, but surgeons stopped the operation when they found the tumour had spread too far.

'Catastrophic bleed'

Mr Hall, referred to as Mr H in the report, later began bleeding from a replacement tube that was inserted in the wrong place while he waited to be transferred to a specialist cancer centre for chemotherapy.

The wound was stitched when it was noticed the tube was not in the right place, but four days after returning to the ward Mr Hall suffered a "catastrophic bleed" caused by the tube wearing through the wall of an artery.

He died, in February 2007, despite the efforts of staff at the Royal Glamorgan Hospital to resuscitate him.

The report said the initial investigation of Mr Hall's tumour was "slow and inadequate" and the nursing he received in relation to his tracheostomy "fell below a standard one could reasonably expect".

"Whilst no amount of apologising can compensate a parent for the loss of a son in such horrendous circumstances, I have nevertheless recommended that both the chair and the chief executive of Cwm Taf trust should provide Mr H's parents with an unequivocal apology for the failings that occurred during the care of their son," said Mr Tyndall.

'Churlish'

He wrote that the trust's refusal of a personal apology was "not sustainable and appears somewhat churlish to refuse to provide [Mr Hall's parent] with an apology in person given that the trust is prepared to issue a letter containing the very same apology".

Cwm Taf Trust told the ombudsman it could not meet his request for an apology in person but would write to Mr Hall's parents - a stance Mr Tyndall called "unreasonable" and "churlish".

The trust said interim chairman Russell Roberts and chief executive Margaret Foster were "extremely sorry for the failings of the former North Glamorgan and Pontypridd and Rhondda NHS trusts in respect of the care and treatment provided" to Mr Hall.

"Cwm Taf NHS Trust fully accepts the ombudsman's recommendations and is now taking steps to implement the actions identified to ensure that safe and effective ENT cancer services are delivered to patients," said the trust.

Mr Hall's solicitor, Astrid Coates, said: "Failures by the trust led to the death of Mr Hall and his family want to know that this will not happen to someone else's son."



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