Health board's apology over patient Marion John's care

Pembrokeshire coroner Mark Layton recorded a verdict of accidental death

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An 84-year-old woman's family have told an inquest she was moved 17 times in 19 weeks between hospitals and a care home before and after heart surgery.

Hywel Dda Health Board have apologised for the care of Marion John, from Narberth, Pembrokeshire.

An inquest at Milford Haven heard the cause of death was bleeding from her aorta while her death certificate said she died of bronchial pneumonia.

Pembrokeshire coroner Mark Layton recorded a verdict of accidental death.

The inquest heard Mrs John was an "independent" and "sharp" lady before the heart valve replacement surgery at Morriston Hospital in Swansea in January 2010.

She developed a series of infections in the wounds in her chest, and also suffered internal bleeding from where the new valve was inserted.

'Gasping for air'

She also fell and broke her leg while at Morriston.

Mrs John died at Withybush Hospital in Haverfordwest on 17 May 2010.

During the inquest, her daughter Megan Busby, a former nurse, criticised the standard of care at Withybush Hospital.

She said her mother had been prescribed oxygen towards the end of her life, but she said that she found her "gasping for air" and not on "oxygen or fluids".

When her mother died, she said that she rang the call bell but no clinical staff arrived until five minutes later.

Mrs Busby also claimed that her mother was moved 17 times during the 19 weeks she spent in hospital, and said that "communication was dire" between Withybush hospital, the care home in Tenby, West Wales General Hospital in Carmarthen, and Morriston Hospital.

She said the family "had lost confidence in the care she was receiving".

Cause of death

She told BBC Wales: "The end of her life was not as it should have been."

The inquest heard that in February 2010, Mrs John was transferred from Withybush to Morriston as her condition had deteriorated.

However, the ambulance had to turn around in Carmarthen as the Swansea hospital no longer had any beds available.

Mrs Busby said she "pleaded with the crew to go on", but they returned to Withybush.

She also claimed the family were not always informed when her mother was moved.

The consultant who performed the heart valve surgery, Dr Aprim Youhana, told the inquest that in April 2010 it was determined that Mrs John had a clot known as a "false aneurysm" near the aorta.

The original cause of death was "bronchial pneumonia" but Mrs John's family disputed this, and a post-mortem examination was requested by the coroner, the hearing was told.

The cause of death given at the inquest was mediastinal haematoma and perforated aortic anastomosis.

'Relevant lessons'

This meant that she died because of a bleed from the site where surgery was performed on her aorta, a typical complication in surgery of someone of Mrs John's age, the hearing was told.

The post-mortem examination showed that there were no signs of bronchial pneumonia.

The coroner said the case had "raised concerns about lines of communication between Withybush and Morriston Hospitals" and that he was sure "lessons would be learned from that".

Afterwards, Iain Robertson-Steele, director of clinical care at Withybush Hospital, said: "The health board regrets the distress caused by the circumstances surrounding this case and apologises to [Mrs John's] family.

"We will review the case in the light of the inquest to ensure any relevant lessons are learned."

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