Proposed measures to put right hospital failings “don’t go far enough” say RCT family on second anniversary of losing their mum

In December, a coroner ordered Cwm Taf Morgannwg University Health Board to improve its procedures for transferring emergency cases after the inquest highlighted that there was not a “clear and robust process” for requesting and chasing up emergency ambulances at the hospital.

Eva Eileen Wheeler, 82, had been an inpatient at the hospital after a hip injury. On 17 February 2020, she suddenly developed a bowel obstruction which led to a perforation and she died the same day.

During an inquest into her death, the coroner stated that “despite appropriate treatment and diagnosis the same morning”, Ysbyty Cwm Cynon had reached the ceiling of care it could offer Ms Wheeler but a communication error between staff meant an emergency ambulance was not called to transport her to Prince Charles Hospital in Merthyr Tydfil, where she should have had “further assessment and care by surgeons”. The coroner was also concerned that the patient was given lunch when she should have been nil-by-mouth and that the on-call surgical registrar had not been consulted.

The coroner’s report stated that the communication failure was unlikely to have changed the outcome for the patient since because of her age and condition, she was not a candidate for emergency bowel surgery. However, a Prevention of Future Deaths Report was issued, ordering the health board to publish the measures that would be taken to ensure these failings would not happen again.

Cwm Taf Morgannwg Health Board has responded to the coroner with a plan outlining the measures that have been taken at the hospital. The document states that a review of its process for both transferring acutely unwell patients to an acute site and for ensuring patients remain nil-by-mouth when necessary have been conducted and that a programme of communication and re-education with the hospital’s staff has taken place.

Ms Wheeler’s daughter, Donna Harris, from Aberdare, said the family had been keen for the circumstances around their mother’s death to be made public to bring to light the things that clearly needed to change at the hospital.

“On the day that Mum died, we were extremely unhappy with the way in which she was dealt with. Her condition deteriorated very rapidly and yet there appeared to be a real lack of urgency from the staff at Ysbyty Cwm Cynon. They were meant to have contacted Prince Charles Hospital as she needed to be moved there immediately but unfortunately that emergency call was never made.

“We feel that this lack of urgency has continued throughout the inquest process. The first inquest was adjourned as the coroner was unhappy with the health board’s initial proposals, and this then prolonged the outcome. It has now been two years to the day since Mum died and we are disappointed that it has taken so long for remedial action to be taken.

“Our concern throughout has been to ensure that the problems we witnessed at the bedside with Mum at an extremely difficult time were made public so that action could be taken to avoid any similar failings in the future.

“Cwm Taf Morgannwg has now published their proposed measures but we do not believe that they go far enough and are still horrified that it has taken our mother’s death to bring these failings to the public’s knowledge. We can only assume that there are many other patients at Ysbyty Cwm Cynon who have been affected by the hospital’s sub-standard processes in the same way as my mother was in her final hours. We very much hope that these measures will be taken seriously to prevent the same thing happening in future.”

The family extended their thanks to Harding Evans Solicitors who were instructed to act in this matter on their behalf.

“We are very grateful for the first-class, professional service we have received, particularly from Sara Uren who was extremely helpful, caring and compassionate during this very emotional time.”