A PREVENTION of Future Deaths (PFD) report has been issued to Betsi Cadwaladr University Health Board regarding a woman from Corwen whose transfer between hospitals was delayed shortly before her death.

Maureen Elizabeth Owens, of Maesafallen Estate, died aged 79 at Ysbyty Glan Clwyd, Bodelwyddan on December 9, 2022.

After concluding the inquest into her death on March 20, John Gittins, senior coroner for North Wales East and Central, has sent a PFD report to the health board regarding this delay.

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Woman died at Glan Clwyd after delays in transferring her to hospital

The inquest had heard that, on December 6, 2022, while at Wrexham Maelor Hospital, Ms Owens was found to have blood clots on her legs, which required urgent vascular surgery at Glan Clwyd.

But her transfer was delayed until about 4am on December 7, and despite eventually undergoing surgery at Glan Clwyd, Ms Owens was pronounced dead roughly 48 hours later.

Dr Andrew Foulkes, the health board’s secondary care medical director for the central area of North Wales, said it uses the Adult Critical Care Transfer Services (ACCTS) to assist patients such as Ms Owens.

Mr Gittins has written in his report that, in Ms Owens’ case, a transfer request should have been booked with ACCTS, rather than with the Welsh Ambulance Services Trust.

He added that evidence given during the inquest suggested an “inadequate knowledge of the use of ACCTS and its operation across the whole of the health board”.

ACCTS was running on a 24/7 basis at the time of Ms Owens’ death, but while that is no longer the case, Dr Foulkes said work is ongoing within the health board to look to return to this.

Gill Pleming, service manager at the Welsh Ambulance Services Trust, said it was not until 3.26am on December 7 – roughly 12 hours after an initial 999 call was made – that an emergency ambulance became available to transfer Ms Owens.

She added that the service was operating at “level three” (severe demand) at the time, with roughly 25 “Amber One” calls ahead of Ms Owens.

Mr Gittins, who recorded a narrative conclusion at the end of the inquest, said that the delays meant Ms Owens “was not afforded the timely care and treatment which may have optimised the prospects of a full recovery”.

Betsi Cadwaladr University Health Board must respond to the PFD report by May 28, detailing action taken or proposed to be taken in this regard.

Otherwise, it must explain why no action is proposed.