Patient's death linked to doctors' communication breakdown

Mr Wareham was treated at Abergavenny's Nevill Hall Hospital, with his GP questioning his discharge

A "significant breakdown in communications" between doctors has been linked to the death of a man who had problems swallowing food.

Brian Wareham's GP from the Richmond Clinic, Newport, said expressing his concerns would have been "futile".

Mr Wareham's condition deteriorated and he died at a hospice in November 2020.

Gwent Coroner Caroline Saunders has called for an investigation and action plan to improve relationships between healthcare providers.

She wants to see measures brought in to remove "obstacles to communication".

• Suicide prompts call for change

• Paramedic took own life after abuse

In a report to prevent future deaths, she said it appeared there was "a significant breakdown in communication, trust and respect between primary and secondary care".

Ms Saunders raised concerns following an inquest into Mr Wareham's death in December, where she said he died from natural causes and concluded this was because of multi-organ failure, oesophageal dysmotility and small cell carcinoma.

The inquest heard Mr Wareham was treated in Nevill Hall Hospital, Abergavenny, with oesophageal dysmotility - problems with swallowing - in May 2020.

It meant he was unable to eat sufficiently.

Clinicians discharged him after his condition stabilised in June 2020 and he was given advice to have a softer, more manageable diet.

However, the inquest heard Mr Wareham's condition deteriorated and he died on 2 November 2020 at a hospice.

The coroner heard from his GP, who said Mr Wareham should have stayed in hospital.

When asked why he did not voice his concerns, the GP said this would be "futile".

Ms Saunders has written to Health Inspectorate Wales (HIW), to ask what steps it will take.

HIW and Gwent's Aneurin Bevan University Health Board have been asked to comment.