Glan Clwyd: Serious failings led to death of man - inquest

David Diamond did not get the care he was entitled to expect, a coroner said.

A man died from bronchial pneumonia in hospital after information regarding his care was not transferred correctly, a coroner's court has heard.

A hearing into the death of David Schofield Diamond found "serious failings" at Glan Clwyd Hospital in Bodelwyddan, Denbighshire.

The 79-year-old was admitted with pneumonia and sepsis two weeks before his death in November 2021.

Betsi Cadwaladr health board told the inquest plans to improve had been made.

Mr Diamond, from Prestatyn, had also tested positive for Covid-19 and was having difficulties eating and drinking. 

He was initially placed in the high dependency area of the Covid ward and his breathing was assisted, the hearing was told.

• No improvement at health board, claim relatives

• Question over size of largest Welsh health board

He was also assessed by the speech and language team, who recommended a soft diet of mildly thickened fluids.

After about 10 days, his condition began to improve and healthcare staff discussed a discharge plan with him and his daughter.

But when he was moved into another area on the same ward, the information regarding his fluids and diet was not transferred with him to the whiteboard above his new bed. 

David Diamond died at Glan Clwyd Hospital in Denbighshire

Three days before his death, a physiotherapist noticed unthickened drinks on his bedside table, some of which had been consumed. 

On 11 November, Mr Diamond's condition deteriorated to a point where an assessment should have been made by the on-call doctor, with two-hourly observations then taken, and the nurse-in-charge informed.

However, no observations were made for seven hours and the nurse-in-charge was not told.

His condition continued to deteriorate and he became unresponsive. A chest X-ray showed there had been aspiration, and he was placed on intravenous antibiotics, but Mr Diamond died on 13 November.

In a statement read to the coroner's court in Ruthin, the bank nurse looking after Mr Diamond overnight, Gwenda Long, said she had assumed the healthcare support team would do Mr Diamond's two-hourly observations.

She said she did not escalate his condition to the nurse-in-charge or the assessment team because she had "misread the term ward-based care" in his notes, and thought medical escalation was not necessary. 

Betsi Cadwaladr health board said an improvement plan had been put in place after David Diamond's death

Giving a narrative conclusion, David Lewis, assistant coroner for north Wales, east and central, said the case showed a "lack of recognition of deteriorating patient" with "human and communication errors" involved. 

Mr Lewis said that though Mr Diamond had died from pneumonia, a natural cause, the aspiration that played a part was not natural, and it was "likely" he aspirated due to consumption of unthickened fluid in the hospital, in spite of recommendations.

Mr Lewis added that though he could not be satisfied that it would have made a difference to Mr Diamond had a doctor been called at an earlier stage when his condition deteriorated, there had been "serious failings" in his care.  

Jane Woollard, associate director of nursing for the Betsi Cadwaladr University Health Board told the inquest that an improvement plan had been put in place following an investigation into Mr Diamond's death, which included the introduction of colour-coded information sheets on dietary requirements which move around the hospital with patients and a plan to train all nurses to carry out swallow assessments. 

Mr Diamond's daughter, Jody Diamond said she felt let down and was "heartbroken" by the loss of her father.