Health board apologises after former Rhyl teacher was ‘failed’

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

Following a full inquest into her death in December, David Pojur, assistant coroner for North Wales East and Central, issued a Prevention of Future Deaths Report with nine points of concern.

The inquest heard that a potentially "lifesaving endoscopy" was unavailable when Mrs Greener was admitted to hospital, and Glan Clwyd’s standby emergency team was not called to help her.

READ MORE:

Potentially lifesaving procedure was unavailable for late Rhyl teacher

Patients ‘beg’ not to go to Ysbyty Glan Clwyd, inquest hears

Standby emergency team wasn't called to help Rhyl woman, inquest hears

‘Devoted’ Rhyl teacher was ‘failed’ by health board before her death

Health board to address nine issues after Rhyl teacher was ‘failed’

Betsi Cadwaladr University Health Board (BCUHB) has now responded to the report, as has Eluned Morgan, Wales' minister for health and social services.

Dr Nick Lyons, executive medical director at BCUHB, wrote: “I would like to begin with offering my deepest condolences to Mrs Greener’s family and loved ones, and to apologise on behalf of the health board for the failings you identified in the care provided to Mrs Greener prior to her death in 2018.

“I hope this letter offers you assurance on the action we will now take to ensure the concerns you raised are addressed and that changes are made to our clinical services.”

Below are each of Mr Pojur’s nine points of concern, and how Dr Lyons and Mrs Morgan responded to them.

1. An out-of-hours emergency endoscopy is still not available at Glan Clwyd Hospital or in this area of North Wales as the provision has “collapsed” at Wrexham Maelor Hospital, so no referrals can be made.

Dr Lyons said Glan Clwyd does not have the demand to support a 24/7 endoscopy service at the hospital, and that cross-site cover at Wrexham Maelor collapsed due to “workforce challenges”.

He added that a gastroenterologist has been appointed at Glan Clwyd and is due to start in April.

Provision of out-of-hours endoscopies is seen by BCUHB as a “corporate risk”, Dr Lyons said, and “remains under review”.

2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department.

Dr Lyons said: “The Emergency Department at Glan Clwyd is fully staffed with junior doctors, in line with the budgeted provision.

“Appropriate staffing levels are put in place through rota management each month, with mitigation in place for management of sickness and unplanned absence.

“The Emergency Department are continuously reviewing staffing in relation to increasing the core numbers to meet national recommendations within the funding envelope available, and work is ongoing to map the resource required to meet demands.  

“Nurse staffing for the Emergency Department is calculated on an annual basis using a triangulated methodology.”

3. There is an ineffective triage and record of triage of patients arriving at Glan Clwyd’s Emergency Department by ambulance.

Dr Lyons said that a waiting room member of Glan Clwyd’s nursing team is in place 24/7, and the triage registered nurse and nurse in charge will address stroke, chest pain and silver trauma.

All ambulance handovers are triaged by a senior nurse, with triage outcomes and decisions recorded electronically on Symphony, a “relatively new” system introduced in March 2022.

4. There is not a clear understanding of when the emergency treatment team should be called.

Dr Lyons said: “Evidence of the call process is included on the National Early Warning Score (NEWS) chart and is clearly visible to all clinicians assessing and reviewing patient recorded observations.

“Use of the NEWS is a standard approach to assessing the acute illness and severity of the individual’s clinical presentation.”

5. There is not a clear understanding of when the major haemorrhage pathway should be engaged.

Dr Lyons said that any staff member can trigger the major haemorrhage pathway and it is printed on the wall in all clinical areas, and is “clearly visible to all”.

He added: “Senior staff who are all very familiar with the pathway are always available and support all resuscitation cases, and can advise if agency staff are unsure or unfamiliar with the pathway.”

6. The health board’s Upper GI Bleeding Management and Principles of Care 2022 is no longer fit for purpose.

Dr Lyons said this was updated in July 2023 and will be reviewed again next month.

7. Any learning from the health board’s investigation report is not adequately shared with its practitioners.

Dr Lyons said that, following similar concerns raised by other coroners, a new incident process is being developed and will be implemented next month.

8. A part of the health board’s investigation report changed in different versions and obscured the reason why the provision of blood products was delayed, meaning issues are not sufficiently identified and actioned.

Dr Lyons said that the health board’s new incident process will introduce a new report template, making it clear which version is the final, approved version of the report.

This, he said, will help in “avoiding any confusion between the final approved version and any draft versions”.

9. Ambulances and paramedics are being kept at the Emergency Department as an extension of the hospital and its staff, due to the Welsh Ambulance Services Trust being unable to get their patients admitted into the Emergency Department and back on active duty.

Mrs Morgan wrote to Mr Pojur: “You will be aware that the urgent and emergency care system in Wales, as with other parts of the UK, has been under often unrelenting pressure for many years.

“This is due to the challenge presented by an ageing population, increasing prevalence of people with multiple chronic conditions, and difficulties in supporting timely discharge of patients to local communities caused by social care capacity issues.

“In terms of progress, we have generally observed improvements in ambulance patient handover although I remain extremely concerned about timeliness of handover in general and particularly at Ysbyty Glan Clwyd and Wrexham Maelor Hospital.”

She added that Welsh Government provided £3million to WAST in 2022 to recruit 100 new staff.

It also provided funding for a pilot, delivered by St John Ambulance, which is supporting about half of people referred to the service to safely avoid transport to hospital.

Mr Pojur said at the inquest’s conclusion that BCUHB had “failed” to put several procedures in place to help Mrs Greener, and he was “concerned” by numerous factors regarding her care.

Mrs Greener’s medical cause of death was recorded as multi-organ failure, contributed to by massive upper gastrointestinal haemorrhage due to therapeutic use of Naproxen.

She was described as a “devoted” wife who “loved children”.

She is survived by her husband, Philip, her daughters and her grandchildren.