NHS' 'failure' over woman's death

A coroner has accused the NHS of systemic failure following the death of a 60-year-old woman who repeatedly called on the service for medical help.

Pembrokeshire coroner Michael Howells, sitting in Ceredigion, said Ruth Hedge died of natural causes, but her cause of death was "aggravated by neglect".

Mrs Hedge's body was found at home in Borth, Ceredigion, on 30 April 2007, an inquest in Aberystwyth heard.

Giving a narrative verdict, Mr Howells said her death could have been avoided.

The inquest heard how divorcee Mrs Hedge made a series of calls for help on 30 April last year, and at one stage dialled 999, but was told she did not need an ambulance.

The pensioner had lived in Machynlleth, Powys, but moved to live in Borth in 2007. The inquest heard she was a heavy drinker and smoker, and had suffered a few falls at home.

"She must have despaired of getting any help"
Coroner Michael Howells on Ruth Hedge

She called 999 saying she had sickness and diarrhoea, was "shaking all over" and was unable to move, but was told by Dr Alan Stevenson that she did not need an ambulance, the inquest heard.

An ambulance was initially dispatched after Mrs Hedge spoke to an emergency controller, but Dr Stevenson stood it down after speaking to Mrs Hedge.

He was working on a pilot project for the Welsh Ambulance Service NHS Trust, which was trying to reduce unnecessary emergency callouts.

But coroner Mr Howells described the pilot, no longer in operation, as a "cost-cutting" exercise.

The trust disputes this and said afterwards the pilot actually increased costs as it employed GPs and its purpose was "to try to provide a more focused frontline response".

The inquest was told how Mrs Hedge had also tried calling her local surgery during the day without success, and after hours she phoned Machynlleth surgery, where she was still registered.

But she was connected to the ShropDoc out-of-hours service, and was told on two separate occasions that it could not help because she lived in Ceredigion - an area it did not cover.

Mr Howells said Mrs Hedge would have been "thoroughly confused" after her series of phone calls.

'Inadequate'

"She must have despaired of getting any help," he said. "She received no medical attention and subsequently died."

He accused the NHS of a "systemic failure", said it was a "gross failure which is more than trivial", and death could have been prevented.

Mr Howells said he would write a report about the failures. He explained that individuals involved in the case were not at fault, but were following guidelines and protocols.

The inquest also heard from Dr Nigel Davies-Waskett, who helped run the ambulance service pilot project.

He said communication between all the agencies involved had been "inadequate", and the project had been suspended following Mrs Hedge's death.

Mrs Hedge's body was not discovered until 9 May 2007, but her cause of death was unascertained.

Following the inquest, Mrs Hedge's daughter Jane and sister Mirriam Hutchings said they were pleased with the verdict.

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