Cwm Taf Morgannwg: Emergency ambulance concern after patient death

Image caption, The 82-year-old patient died after she developed a bowel obstruction which led to a perforation

Health officials have been ordered to improve procedures for transferring emergency cases after the death of an 82-year-old patient.

A coroner is concerned there was not a "clear and robust process" for requesting and chasing up emergency ambulances at Ysbyty Cwm Cynon in Mountain Ash, Rhondda Cynon Taf.

Eva Eileen Wheeler was an inpatient at the hospital after a hip injury.

Cwm Taf Morgannwg University Health Board has until February to respond.

On 17 February 2020, she suddenly developed a bowel obstruction which led to a perforation. She died the same day.

The coroner for south Wales central, Rachel Knight, said that "despite appropriate treatment and diagnosis the same morning", she was not transferred to Prince Charles Hospital in Merthyr Tydfil, where she should have had "further assessment and care by surgeons".

An inquest into her death heard that a communication error between staff meant an emergency ambulance was not called.

Ms Knight said the failure was unlikely to have changed the outcome for the patient because of her age and condition.

She has issued a Prevention of Future Deaths report to ensure the mistake is not repeated.

The coroner was also concerned that the patient was given lunch when she should have been nil-by-mouth and that the on-call surgical registrar had not been consulted.