Pamela June Conway · Prevention of Future Deaths report

On the 13th of November 2014 I commenced an investigation into the death of Pamela June Conway (DOB 13.6.43, DOD 8.11.14). The investigation concluded at the end of the inquest on the 23rd of August 2016 and I recorded a conclusion that the death was due to natural causes which were exacerbated by delayed medical treatment.

The Circumstances of the death are that for multifactorial reasons there was a delay of around 21 hours before the deceased received antibiotics for an infected knee and that during the course of this period she went into irrevocable septic shock.

Amongst the reasons for the above delay was the length of time it took for Mrs Conway to be discharged from the ambulance to the hospital on the 10th of October 2014. On this date the emergency department at Wrexham Maelor Hospital was extremely busy and despite an agreed handover time of 15 mins, Mrs Conway waited in the ambulance for 2 hours and 50 mins. The longest waiting time on that date for a patient handover was one minute short of five hours.

Whilst this delay alone did not result in her death, it did form a part of the cumulative delays by which Mrs Conway was denied the best chance of having her knee infection successfully treated and hence not going on to develop sepsis.

1. Evidence at the inquest indicated that discussions were taking place between different departments within BCUHB with a view to agreeing a protocol to establish an appropriate care pathway for patients presenting to the hospital with an infected prosthesis, however nothing had been finalised regarding the same.

2. Furthermore evidence indicated that although it was always intended that antibiotics would be administered once the patient's knee had been aspirated, there was a delay of almost two hours between this procedure and the administration of antibiotics (a delay which was explained by being due to “normal hospital procedures”).