Chances missed to help man who died in waiting room

Opportunities were missed to help a man who died in a hospital emergency department waiting room, a coroner has said.

Former woodworker William Phillips, 76, of Linden Avenue, Chirk, Wrexham, had symptoms including fever and fluctuating heart rate and blood pressure rates when he arrived at Wrexham Maelor Hospital on 9 September 2020.

He was sent to a waiting room where he waited for five hours before being found unresponsive by other patients.

The inquest in Ruthin was told Mr Phillips, who had a number of health conditions, died from cardiac arrhythmia due to coronary artery atheroma.

Senior Coroner for north Wales, east and central, John Gittins, said Mr Phillips' care and treatment had been "suboptimal".

He said Mr Phillips was not given blood tests or an ECG on admission after being triaged.

"Whilst there was an absence of evidence to prove he would have survived with earlier treatment, the absence of any investigations denied him the opportunity of receiving any appropriate care or treatment," he added.

The inquest heard from a number of witnesses, including Mr Phillips' widow, Brenda Phillips.

She said her husband was initially assessed at home while they waited for an ambulance.

But she decided to drive him there after waiting four hours for it to arrive.

Her husband had been met at the door by a nurse who said Mr Phillips' observations were normal.

Mrs Phillips was not allowed to stay with him due to Covid-19 restrictions which were in force at the time.

"I remember being so worried and upset, but felt he was in best place", she said, adding it was the last time she had seen him alive.

She received a call in the early hours of the morning telling her Mr Phillips had died.

A CCTV timeline was described in court of Mr Phillips showing signs of becoming increasingly unwell in the waiting room.

The court also heard from Emma Davies, a nurse who triaged Mr Phillips when he arrived at the hospital.

She said it took place during the second wave of the Covid pandemic when nursing was challenging and triage was "difficult".

Ms Davies added she had not taken bloods from Mr Phillips because triaging was not taking place in the consulting room at the time.

She agreed with the findings of an internal review that her triage of Mr Phillips had been inadequate.

She also said she did not recall seeing the first responders report handed in by Mrs Phillips which referred to her husband's fluctuating heart rate.

Dr Robin Roop, head of the Wrexham Maelor emergency department, said the pandemic had been "an ever-changing situation".

He added the subsequent investigation had led to improvements in the delivery of care and the triage process.

"We've continued to improve and strengthen in terms of pathways for patients," he said.

Betsi Cadwaladr University Health Board told the hearing it had made "a significant amount of improvements and changes" since Mr Phillips' death.

In a statement, Mr Phillips' family said he was "the heart and soul of the family, and that they were devastated by his loss, and the circumstances by which it happened".

It added: "The events of that day and night will haunt and stay with us for the rest of our lives."

After the hearing, Adam Hodson, who represented Mr Phillips' family, said this was a tragic example of failings in the NHS which were exacerbated by the Covid pandemic.

"The conclusion today confirmed that Bill lost the opportunity to receive appropriate care and treatment, and as a consequence he died alone in the waiting room," he said.

"Had he been seen and received treatment, the family believe he would still have been with us today."