A PREVENTION of Future Deaths (PFD) report has been issued after an inquest found that a Rhos-on-Sea woman died at Ysbyty Glan Clwyd after “several missed opportunities to optimise her care”.

Margaret Kelly, 82, of Marston Drive, died at the Bodelwyddan hospital on March 31, 2022, just three days after undergoing surgery for a hernia repair.

At a full inquest into her death, held in Ruthin on October 5, John Gittins, senior coroner for North Wales East and Central, recorded a narrative conclusion.


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Mrs Kelly likely suffered bowel damage during her surgery on March 28, the inquest heard, as the following day, she attended Glan Clwyd’s Emergency Department (ED).

She had been unable to get an answer from the telephone number she was given, and was not seen by a surgical doctor at Glan Clwyd for several hours.

By the morning of March 30, when her condition had deteriorated considerably, further emergency surgery was undertaken to repair her bowel perforation.

Mr Gittins, in his PFD report issued to Betsi Cadwaladr University Health Board (BCUHB), wrote: “As a result of there being several missed opportunities to optimize her care and treatment, Mrs Kelly no longer had the resilience to recover from this procedure.

Evidence was given at the inquest that, when the deceased attended the ED, it was at ‘level four’ escalation - the highest level.

This was said to be “far from unusual” at the time, and that between March 2022 and the present day, the department would usually be operating between levels three and four.

Mr Gittins added: “I am concerned that the pressure on clinicians and other staff is unsustainable and that delays in treatment will result in deaths.

“I do not consider that the operating practices within the department are a direct cause for concern. However, I am concerned that insufficient or ineffective strategic planning and support is being undertaken.

“I would, therefore, wish to hear from those responsible at an executive/managerial level as to the steps which are being taken to reduce pressures within the department at Gian Clwyd.”

BCUHB is duty-bound to respond to the report by December 4, containing details of action taken or proposed to be taken, and setting out the timetable for action.

Otherwise, the health board must explain why no action is proposed.