A MAN from Rhyl who died at Ysbyty Glan Clwyd after developing stomach ulcers received “erroneous” treatment at the hospital, an inquest heard.

David Milner died aged 74 on October 26, 2021 at the Bodelwyddan hospital, having initially been admitted there 10 days earlier.

Following a full inquest into his death, held in Ruthin yesterday (January 25), John Gittins, senior coroner for North Wales East and Central, recorded a conclusion of death arising from natural causes.

Mr Milner’s medical cause of death was noted as upper gastrointestinal haemorrhage due to stomach ulcers, contributed to by atrial fibrillation and Warfarin therapy.

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The inquest heard that Mr Milner, a Prestatyn-born father of two and retired chartered accountant, had suffered from Type 2 diabetes prior to his death, and had an increased body mass index.

Concerns had also been raised to Mr Gittins about the “thoroughness and robustness” regarding the monitoring of Mr Milner’s treatment during his time in Ysbyty Glan Clwyd.

Lowri Kirkham, Mr Milner’s daughter, said that, two days after his admission, she was told that nurses were “too busy” to talk to her.

The following day, she was told he had been moved to a different ward in the hospital.

On October 20 and 21, she said she had no reply from the ward her father was on after 45 minutes of trying to contact staff, though her mother had been told that Mr Milner was improving.

When, on October 23, Mrs Kirkham was told her father was well enough to be discharged, she expressed her surprise at this, and asked for notes to be re-checked; upon doing so, it was felt he should, in fact, stay in hospital.

Mr Milner was again moved to a different ward a day later; when Mrs Kirkham asked for a doctor to call her, she said she was told: “They don’t really do that.”

Mrs Kirkham said she and her family were waiting in a corridor at Glan Clwyd on October 26 when they were told that her father had died at approximately 11.15am.

Dr Zvonomir Miric, a consultant gastroenterologist at Glan Clwyd at the time, said he was unsure as to why Mr Milner was transferred between wards.

He ordered a full set of blood tests to be carried out for Milner on October 25, but this was not completed.

In undertaking Mr Milner’s post-mortem examination, Dr Huyam Abdalsalam found a “massively enlarged” heart and two adjacent stomach ulcers.

Mr Milner was being prescribed roughly 0.75mg of Warfarin – medication to stop blood clotting – while in Glan Clwyd.

Though, Dr Aram Baghomian, who tended to Mr Milner on October 25, said his “small dose” of Warfarin was something he “can’t understand”, labelling it “erroneous”.

He added that, when he first saw to Mr Milner, he had “extremely low” blood pressure, was vomiting blood, and was generally “too poorly” for examinations to be undertaken as to where the bleeding was stemming from.

Asked by Mr Milner why such a dose of Warfarin was administered, he said: “I do not know”, adding that he assumed his transfer between wards was to cope with patient flow in the hospital.

Dr Baghomian also said that the relocating of Mr Milner in Glan Clwyd would not have exacerbated his illnesses.

“I agree it (moving patients) doesn’t sound best practice, but sometimes, needs must,” Mr Gittins said.

Following Mr Milner’s death, Dr Baghomian said greater care has been taken to Warfarin management at Glan Clwyd.

Indeed, he said he discussed Mr Milner’s case, and the lessons to be learnt from it, at a subsequent clinical governance meeting.

Concluding, Mr Gittins said it appeared that, despite the challenges Mr Milner and his family faced during his time in hospital, none of the contextual factors appeared causative of his ulcers, or the bleeding which later ensued.

Offering Mr Milner’s family his condolences, he said: “What we have is a natural disease process – namely, the ulcers - which have run their course, leading to death.

“Even when David was in hospital, even with the challenges around with communication at the time, at no point have you ever given up, in terms of finding out what happened.

“While the communication and lack of satisfactory information may have been very challenging, it doesn’t seem to have made a great deal of difference.

“The die was already cast, but I’m sure you miss him hugely.”