CHANGES have been put in place after an elderly man waited eight hours for a scan which should have been done within ‘ten minutes’, an inquest heard.

John Garston, 90, of Caergwrle died on September 30, 2018 at Wrexham Maelor Hospital after he had fallen onto a glass table at home.

Daughter Anne Powell told the inquest, held in Ruthin, that Mr Garston – who retired as an architect at the age of 86 – was ‘very keen to keep busy’.

After the death of his wife in 2018 he ‘struggled a little’ but ‘slowly adjusted to living alone’.

Mr Garston, who had received a pacemaker five years ago for heart disease, had fallen a couple of times in the months leading to his death, but ‘nothing serious’.

On September 26, his granddaughter had a call around 2.30am from a neighbour who had said an ambulance was outside.

Upon entering the property, Mr Garston was lying on the floor speaking to ambulance control on the phone.

Mr Garston explained he had gotten up to go to bed but got his ‘feet in the wrong order’ when he fell onto the glass coffee table before ‘crawling’ to phone an ambulance.

He was admitted to Wrexham Maelor where he waited around eight hours for an x-ray, which showed multiple fractured ribs and a shadow on the lung.

Despite being ‘alert and chatty’, the hearing heard how Mr Garston was sent to the high dependency unit due to being at a high risk of infection.

Mrs Powell said when they visited he seemed fine, but at around 1pm on September 29, she said Mr Garston was ‘different’ and ‘crying out in pain’, he appeared to be coughing and holding his right side.

He was moved to another ward after appearing ‘stable’ however upon visiting at 6pm, the family said he was ‘confused and agitated and very unhappy’.

Mrs Powell said she alerted the nurse as he ‘was not himself’ and around 1am the following day, they received a call alerting them to the hospital as Mr Garston was ‘very poorly’, but he had passed away before they got there.

Mrs Powell added: “We would never have left if we had known he was so close to passing away.

“Dad was a real character, he knew everyone and was very well liked. He loved to learn and didn’t accept the limitations of age. He will be very sadly missed by us and all of the family.”

At the inquest, the family raised concerns over the eight-hour wait to be seen and whether he was fit to move wards when he needed monitoring.

Post-Mortem results showed significant haemorrhage from a chest injury, but the pathologist could not determine when that occurred, however the sudden deterioration suggests towards the end of his life.

Kelly Jones, acute surgical matron said Mr Garston was clinically stable on the high dependency unit so was moved. However, he showed a deterioration as his oxygen and blood pressure levels decreased.

Ms Jones said Mr Garston decreased further as he became ‘unresponsive to pain’ and a decision was made to reverse the morphine which improved his condition.

However, the inquest heard a short time later he deteriorated and ‘suddenly arrested’.

Coroner for North Wales (East and Central) David Pojur, heard how the protocol is to check every four hours but due to the prior deterioration, the nurse ordered the check to be done ‘as soon as reasonably practical’ and he was checked after an hour and an half.

Mr Pojur also heard how due to Mr Garston’s condition, he should have been seen within ten minutes upon arrival in A&E and despite the fact the wait ‘would not have made a difference in this case’, it was ‘still too long’.

Mr Garston was moved due to the lack of spacing in the critical care unit and he had been stable, and a management plan is still put in place when they are discharged.

Coroner Pojur recorded the cause of death as heart disease and chest injury from the fall as he ‘essentially had a weak heart’.

He added: “It’s quite clear he was a very intelligent man who is clearly sorely missed by his family who have come before me and raised a number of issues.”

Mr Pojur said he had taken into consideration the steps the health board has put in place since Mr Garston’s death but will ‘not hesitate’ to take action if events were to be repeated in a similar way.

The inquest heard how the Health Board has taken steps to prevent future events, such as looking at how other health boards deal with rib fractures. They have put in place a new model which captures a patient’s risk and category they are in and have trained all frontline staff in using this model.

They have also raised awareness of the large risks that rib fractures pose and will ensure patients are ‘seen sooner and assessed properly’.

The Health Board is also in negotiations with Stoke hospital for a potential referral pathway for patients of a high risk.