Rhyl man who died after heart attack ‘let down badly’ by hospital

Michael Hugh Matthews, 48, of Walford Avenue, attended the hospital’s emergency department (ED) at 6.43pm on March 2, 2020, complaining of chest pains.

The transport manager was triaged more than one hour later before being sent back to the ED’s waiting room, where he collapsed at 11.23pm.

At a full inquest into Mr Matthews’ death, held in Ruthin today (April 11), it was heard attempts to then resuscitate Mr Matthews were unsuccessful, and he was pronounced dead at about 12.30am on March 3.

Ysbyty Glan Clwyd, Bodelwyddan (Image: Newsquest)

Senior health board staff members accepted that the hospital “let Mr Matthews down badly”, and that the care he received “fell short of expectations”.

Mr Matthews’ sister, Julie, said that he was living with and caring for their mother, a dementia sufferer, at the time of his death.

She said: “The night that he died was awful. For us, as a family, I’m just tormented.

“He was in a crowded room full of strangers. We think Mike should have at least been given an opportunity to still be here with us.”

Ms Matthews said her brother never said anything to her about any health difficulties, but had sent a message to the family’s WhatsApp group chat at about 1.50pm on March 2 complaining of a “constant pain” which he thought was indigestion.

Indeed, today’s inquest heard that Mr Matthews was not prescribed any medication at the time of his death.

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Further WhatsApp messages sent from Mr Matthews following his arrival at the hospital suggested to his sister that he “seemed to be getting impatient”.

Colleagues of Mr Matthews at Brakes Foodservice’s Bodelwyddan depot recalled how he “seemed restless” on March 2, and appeared gradually more uncomfortable as the day went on.

But they added they were shocked to discover that he had died just hours later.

A co-worker said Mr Matthews had told her that he decided to attend Glan Clwyd’s ED after vomiting at work that afternoon.

Sophie Finney, a registered nurse at Glan Clwyd, was moved to triaging patients that day due to staffing shortages.

It took Mr Matthews roughly 70 minutes to be triaged, despite the hospital’s aim of triaging each patient within 15 minutes of their arrival at the ED.

Michael Matthews with his two sons. (Image: Julie Matthews)

She said she remembers “an extremely difficult day”, where the waiting room was severely overcrowded, “like it was yesterday”.

There was “no flow in departments” and “nowhere to move patients”, she added, with doctors asking her to hand out treatments to patients in the waiting room.

Ms Finney said she felt “emotionally and physically” affected by the events of March 2, having been told by senior staff to “just do my best”.

She remembered Mr Matthews as being “really chatty”, adding that he “didn’t look critically unwell” and that he did not make her aware that he felt nauseous.

But she recalled he told her that the pain was radiating to his back – a “red flag for a cardiac problem”.

He was categorised as “urgent”, with the expectation he would be seen by a doctor within the next 15 minutes.

Mr Matthews required an electrocardiogram (ECG) and a blood test promptly, she said, and it was her job as a triage nurse to request them.

These tests, though, did not materialise.

She added: “I would never have wanted any family to go through this. I was the last person to assess him.

“It’s something I’ve got to live with for the rest of my career.

“My best wasn’t good enough. I couldn’t keep up with the triaging.”

The full inquest was heard at County Hall, Ruthin today (April 11). (Image: Newsquest)

Statements provided from Ms Finney’s colleagues echoed her sentiments that this was an extremely busy day, adding that there was “no verbal communication” between colleagues finishing and starting shifts; handover notes were left regarding Mr Matthews, but not picked up.

At one stage of the evening, it was heard, there were 84 patients attending ED - 11 of whom were situated on the hospital corridors, with 16 awaiting beds on wards.

The longest wait was 23 hours.

Mark Pye, clinical site manager at the hospital, said he felt he had done “all that I could do to balance the risk during this shift”.

Consultant pathologist Dr Mared Owen-Casey performed Mr Matthews’ post-mortem examination, returning a provisional cause of death of a heart attack.

Prof Stephen Brecker, a consultant cardiologist at St George’s Hospital, London, said Mr Matthews had suffered a “quite unusual” heart attack.

“I would have expected him to have appeared more unwell,” he said.

“As a cardiologist, we would expect a patient with chest pains to have a prompt assessment and ECG.”

But Prof Brecker added that, even with more prompt treatment, Mr Matthews’ chances of survival would have been slim, and that his collapse at 11.23pm had been “destined to happen for a few hours”.

Dr Tom O’Driscoll, consultant in emergency medicine and clinical director of emergency care at Glan Clwyd, was on duty on the evening of March 2.

He said that “Mondays tend to be our busiest day” at the ED, but on that day, the number of occupants was among its highest for a single day in 2020.

The hospital now has a digital process, called Symphony, to essentially “fast-track” patients with chest pains to ECGs and blood tests.

Its previous “analogue” system had “clearly let us down, in this case”, Dr O’Driscoll conceded, and “let Mr Matthews down badly”.

He added that in his 10 years at Glan Clwyd, this was “the only time I’ve seen that occur”, where a patient with chest pains was not promptly triaged and where the outcome was ultimately fatal.

Since then, the hospital has introduced the “failsafe” of waiting area nurse, with a purpose-built space.

It has also created a bespoke investigation suite to undertake diagnostic tests, Dr O’Driscoll added, which can house as many as four patients simultaneously, and which has reduced “bottlenecking”.

Paul Andrew, the hospital’s director of operations, said the average time of discharge has since been brought forward by 30 minutes per patient, and that triage times have, on average, been below 30 minutes for five of the last six months.

Dr Tom Davis, medical director at BCUHB, conceded the care Mr Matthews received “fell short of expectations”, and offered his condolences and apologies to Mr Matthews’ family.

He added: “I do believe many concerns raised by this tragic case have been addressed in specific terms, but I do think there’s more that we can do.

“Flow remains a slowly progressing challenge for us.”

John Gittins, senior coroner for North Wales East and Central, recorded a conclusion of death arising from natural causes.

He said that a “lack of diligence and care” had been demonstrated.

Mr Gittins said: “The failure to undertake tests by way of ECG is not one which stems from systemic issues, but more so to do with individual issues with regard to communication.

“On the balance of probabilities, given the delayed presentation (of Mr Matthews at Glan Clwyd), this was not a condition which was survivable.

“In this instance, while the ED remains the subject of intense scrutiny, it would be inappropriate to make a final decision on whether to make a prevention of future deaths report.

“What I don’t want to lose sight of is this particular man. This is a dad, a brother, a loved one, that people miss and care for.

“It is not an acceptable situation… that’s why I want to see the numbers crunched in relation to this.”

Mr Gittins requested the relevant figures from BCUHB regarding ECG waiting times by the end of May.