A TEACHER from Rhyl who died at Ysbyty Glan Clwyd after vomiting blood was “failed” by Betsi Cadwaladr University Health Board, the final day of the inquest into her death has heard.

Vivienne Greener, who taught at Ysgol Mair for 30 years, died at the Bodelwyddan hospital on March 20, 2018 aged 64 after coughing up blood earlier that night.

A medical cause of death for Mrs Greener was given as multi-organ failure and a gastrointestinal haemorrhage, with contributory use of a prescribed drug, Naproxen,

At the fifth and final day of the full inquest into her death, held in Ruthin today (December 18), it was heard that the health board had “failed” to put several procedures in place to help Mrs Greener.

David Pojur, assistant coroner for North Wales East and Central, said he was “concerned” by numerous factors regarding her care, and said he will issue a Prevention of Future Deaths report to the health board, the Welsh Minister for Health, and social services.

In his findings, Mr Pojur said there was an “insufficient” number of medical staff on the night in question, that a clinical manager was “never alerted”, and that Mrs Greener suffered an “unacceptable” delay in being provided with blood products.

He said the delay was a “missed opportunity” in administering care to Mrs Greener, and that an emergency team should have been summoned, which practitioners “failed to do”.

Mr Pojur added that her treatment in the resuscitation unit was an “unacceptable” place for the procedure, and that had Mrs Greener been resuscitated sooner, this would have given her more of a chance of remaining alive for longer for a possible operation.

Reaching a conclusion, Mr Pojur said: “The health board failed to transfer the patient to the emergency department, failed to provide documented evidence of triage, failed to recognise the deterioration of the patient, failed to trigger a pathway for help, and failed to document a clinical review.

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“The health board failed to escalate the situation earlier and failed to obtain blood products urgently.

“In my opinion, action should be taken to eliminate or reduce the risk of such circumstances.”

He said that the health board’s investigation report into her death was “concerning”, due to conflicting points being made, and questioned the importance of such a report.

Mr Pojur said there was an “insufficient” plan to provide out-of-hours endoscopy procedures at Ysbyty Glan Clwyd, adding that this had also “collapsed” at Wrexham Maelor and that “things have gotten worse”.

He noted several matters of concern, including the collapsed provision of emergency endoscopy, insufficient numbers of doctors and nurses for the number of patients, and “no clear understanding” of when the emergency team should be engaged.

Mr Pojur said the health board’s principles of care were “no longer fit for purpose”, and that action should be taken by the Minister for Health and the health board.

Mrs Greener, who was described as a “devoted” wife who “loved children”, is survived by her husband Philip, her daughters and several grandchildren.

Addressing Mr Greener, Mr Pojur said: “Mr Greener, you had to wait a long time to have your concerns faced in court.

“I hope you have, through the inquest procedure and the representation you have had, found some of the answers which you needed.

“I’d like to mark the very dignified way you sat through difficult evidence, even more so given the amount of time since her death and having to relive it.

“I offer you, your daughters and your grandchildren my condolences.”