Betsi Cadwaladr: Man died after missed hospital test

A 48-year-old man who died of cardiac arrest was not given a heart rhythm test because of hospital handover errors, an inquest has heard.

Michael Hugh Matthews was considered an urgent case at Glan Clwyd Hospital, Denbighshire in March 2020.

But more than three hours after being assessed, he collapsed in the waiting room and resuscitation attempts failed.

Betsi Cadwaladr University Health Board said that Mr Matthews was "failed".

However a cardiologist said that it was unlikely he would have survived, even if he had been investigated promptly.

The A&E department at the hospital has been criticised by several reports in recent months.

Mr Matthews, from Rhyl, Denbighshire, was at work in Bodelwyddan on 2 March 2020 when he started having pains in his chest.

He thought it was indigestion or trapped wind.

During the afternoon he asked his sister - who worked at Glan Clwyd Hospital - how busy it was at A&E, but waited until he finished work before going.

After arriving at about 18:45 GMT, he was assessed by triage nurse Sophie Brewerton at 19:56, who put his case in the urgent 'orange' category, and recommended an electrocardiogram (ECG) - which tests heart rhythm - and blood tests.

She told the inquest in Ruthin on Tuesday that a healthcare support worker told her the night shift staff would have to deal with the tests, which she had requested by placing a piece of paper in a box.

But night shift staff, who started work at about 20:15 GMT, were not given a "formal handover" or made aware that the tests needed to be done, the inquest heard.

In a written statement, one staff member said there was "no verbal communication" and "no notes left" regarding any outstanding ECGs.

Mr Matthews collapsed in the waiting room and, although staff attempted to resuscitate him, died at about 00:30 GMT.

The emergency ward was extremely busy that day, and Mrs Brewerton said there was "nowhere to move patients".

"It was just an awful day and I just couldn't keep up with the workload," she told the hearing.

At one point there were 84 patients at the department, with 11 in corridors. Some had been waiting 23 hours for a bed.

Mrs Brewerton said that, when she assessed Mr Matthews, "he didn't look critically unwell" and was "chatty".

Independent cardiologist Professor Stephen Brecker told the inquest that Mr Matthews' heart had already sustained a large amount of damage and that it was unlikely, even if he had received an ECG promptly, that he would have survived.

"Even if he had gone to the catheter lab at that time, I have to conclude that the outcome would not, on balance, have been different," he said.

Representatives of Betsi Cadwaladr University Health Board apologised to the family of Mr Matthews, and said they had been "failed" by the handover and ECG ordering system in place at the time.

Dr Tom O'Driscoll, a consultant in emergency medicine who was on call that night, said the "analogue paper system [has] clearly let us down very badly" and that "it let Mr Matthews down badly" too.

Referrals for tests such as ECGs are now done digitally and Dr O'Driscoll said the new system has "become the handover tool" in which a case like Mr Matthews' is "much less likely to occur".

The inquest also heard that staff numbers have increased from 12 to 15 or 16, and a doctor can now sit in with the triage nurse.

Dr Tom Davis, medical director of integrated health community for the central area of the health board, said that "many of the concerns raised in this case have been addressed in specific terms".

But he added that "there is more to be done", especially in improving patient flow.

Coroner for North Wales East and Central, John Gittins, ruled that Mr Matthews died of natural causes.

He asked the health board to provide further data on ECG waiting times before deciding whether to issue a Prevention of Future Deaths report.

In a statement, Mr Matthews' family described him as "an amazing dad, son, brother and friend to so many people".

"Every day, we miss his daft sense of humour, his bad jokes, his love of Liverpool FC and his huge love and devotion for his sons, Louis and Alfie, who he adored," he said.

"We hope following the findings of this inquest that improvements will be made in the emergency department and that no other family will go through what we have experienced over the past three years."