Delays in the diagnosis of an elderly woman's aneurysm and subsequent delay of her transfer to a specialist hospital could have affected the outcome on the day she died, an inquest has heard. Ruth Susan Coles died at Withybush General Hospital on May 17, 2022 as a result of complications of an ascending aortic aneurysm.
An inquest into her death on Friday heard the 77-year-old had lived at Gibbas Way in Pembroke Dock with her husband Roy. She had some medical issues, including a hiatus hernia, and had to retire early from her job as a carer, but was functioning well, the inquest, at Haverfordwest County Hall was told. On May 16, 2022, she had been feeling unwell during breakfast, experiencing chest pains, which she initially attributed to her condition.
She drank some water, and the pain passed for a short period before returning, and she started feeling a pain between her shoulder blades. She decided to telephone her neighbour, a retired nurse, describing how she was feeling, who then came over to see her. But the pain increased, and she collapsed onto the floor. For the latest Welsh news delivered to your inbox sign up to our newsletter.
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The ambulance service was called just before noon and paramedics attended ten minutes later. An ECG machine was placed onto Mrs Coles and revealed there was an "anomaly" regarding her cardiac output.
Evidence was given during the hearing regarding the pathway to transfer patients to Morriston Hospital's cardiac centre, with certain criteria needing to be present, including what was referred to during the hearing as an elevated ST. Her ECG was sent to the hospital, but it was determined hers was not a case that would be dealt with along the pathway, and instead saw the pensioner taken to the nearest emergency department for care and further tests.
She was taken to Withybush Hospital in Haverfordwest, where she underwent assessment, and was referred to the surgical team for input further to what was deemed a possible intra-abdominal problem. It was decided that a CT scan should be carried out, but there was significant delay in it taking place, despite the inquest hearing the equipment was available. Clinicians at the hospital had been under the impression it was not working, the inquest heard.
Acting senior coroner Paul Bennett explained how at the time the CT had been reported on, it revealed how Mrs Coles has an ascending aortic aneurysm, which needed immediate transfer to Morriston Hospital's cardiac unit. He said: "Sadly, in the time it took to initiate the transfer, Ruth's condition deteriorated, and she suffered a cardiac arrest. She was declared deceased at 3.50am on May 17, 2022."
Returning a narrative verdict, he added: "In light of evidence, it cannot be said that there was an inevitable fatal outcome from the presence of the ascending aortic aneurysm. A timely diagnosis and transfer may well have materially affected the position. It went untreated, following the delay in its diagnosis and had it been treated, would have affected the outcome." Join our WhatsApp news community here for the latest breaking news.