Man died at Glan Clwyd after ‘missed opportunities’ for ‘timely’ care

Eric Thompson died at the Bodelwyddan hospital at the age of 81 on December 28, 2022.

Following a full inquest into his death, held at County Hall, Ruthin on June 14, coroner Kate Robertson has issued a Prevention of Future Deaths report to Betsi Cadwaladr University Health Board.

Ms Robertson, assistant coroner for North Wales East and Central, recorded a narrative conclusion at the inquest.

On December 27, 2022, Mr Thompson presented at Glan Clwyd with “confusion” and “poor mobility”, having previously been treated for a urinary tract infection.

But after blood tests revealed later that day that he had high levels of potassium (hyperkalaemia), there was initially no answer when the hospital’s emergency department was contacted by the laboratory where the bloods were taken.

The results were eventually relayed to the department about an hour later, but were not documented or escalated.

Later that evening, while Mr Thompson remained in the emergency department, a clinician noted he had a high NEWS (National Early Warning Score) of seven.

Ultimately, though, he did not receive treatment for hyperkalaemia, and died shortly after going into cardiac arrest at 2.50am on December 28.

Both hyperkalaemia and diabetes mellitus were deemed to be contributory factors in Mr Thompson’s death.

The inquest into his death heard that there was no electronic system by which a laboratory can send blood tests results to the emergency department quickly and efficiently, with an alert to indicate abnormal results.

Instead, the system used was said to rely on “person-to-person discussions”, and for this to then be “escalated as necessary”.

Betsi Cadwaladr University Health Board is duty-bound to respond to Ms Robertson’s report by no later than August 9, detailing the action it has taken or proposes to take to address the concerns raised.

Otherwise, it must explain why no action is planned.