Vera Hilda Williams · Prevention of Future Deaths report

On 3 November 2014 I commenced an investigation into the death of Vera Hilda Williams , aged 77. The investigation concluded at the end of the Inquest on 18 September 2015. The conclusion of the inquest was – Medical Cause of death: - 1a. Massive Gastrointestinal Tract Haemorrhage due to 1b. Oesophageal- Aortic Fistula due to 1c. Oesophageal Rupture. Conclusion of the inquest: Death was due to an accident.

Mrs Williams attended the Emergency Department of Glan Clwyd Hospital on 10 October 2014 complaining of pain after eating toast. She was given pain killers and observed to be swallowing. Mrs Williams was examined . Upon a review the pain had been resolved and she was sent home. The Emergency Department took the view that there had been an obstruction which had resolved itself.

Mrs Williams returned to the Emergency Department on 23 October 2014 complaining of pain in the left side of her face and back of her neck. Usual Observations and bloods taken. Her chest was examined but not x rayed. Mrs Williams was discharged home at 02.20 hours with oral antibiotics and painkillers. She was suspected of having a mild upper respiratory tract or urinary infection.

Mrs Williams attended the Emergency Department at 19.09 after calling an ambulance at 17.46 on 24 October 2015. She had coughed and vomited a blood clot. She was generally unwell. At 16.00 hours on 25 October 2015 after other investigations including Chest Xray, Bloods, General observations and physical examination , a CT scan revealed that Mrs Williams had a ruptured aorta . It is probable that this was caused by swallowing the toast which was complained of on her first visit to the emergency Department on 10 October 2104. Surgical intervention was not appropriate for Mrs Williams and she died on 28 October 2015 at Glan Clwyd Hospital.

The presentation for Mrs Williams was different on the three separate occasions that she attended the Emergency Department. The Doctors on call had to rely upon Mrs Williams to tell them that she had been admitted previously and what occurred on those previous visits to the Emergency Department. In this case it was only the CT Scan which showed the Oesophageal Rupture. The presentation of Mrs Williams on the 10th and 24 October was not such that a CT Scan could reasonably be expected to be carried out on the examination and presentation of Mrs Williams on those occasions.

(1) Doctors and staff in the Emergency Department do not have a DIGITAL CENTRAL RECORD ( ie on a computer database) of who has passed through the Emergency Department , their symptoms and what treatment they have received.

(2 )Doctors must rely upon the patient telling them what has happened and then there is a delay whilst previous paper notes are located and retrieved. This lack of easy and swift access to accurate information is fraught with risks for patients and clinicians in the arena of Emergency medicine where time is of the essence in coming to a diagnosis. An accurate history is an essential tool in coming to that diagnosis. Any delay can have potentially fatal consequences for a patient.