'Gross failure' in care of Wrexham sepsis death mum as her family plan legal action

After hearing of “gross failures” in the care of Samantha Brousas, her partner and daughter also called for the resignation of the Board’s chief executive Gary Doherty.

At a hearing in Ruthin, however, Joanne Lees, assistant coroner for North Wales East and Central, ruled that although she found there had been gross failings they did not lead to the death of the 49-year-old, who died of multi-organ failure from sepsis.

Last month an inquest heard that Miss Brousas, of Bryn y Groes, Gresford, had been unwell since January, 2018, and after being unable to shake off a cough was prescribed an inhaler January 31.

A few weeks later she began to feel very ill and was struggling to breathe. She was vomitting and had diarrhoea, and consulted her GP who diagnosed her as having gastric flu or gastric enteritis.

Her condition deteriorated and on February 21 her daughter Sophie, a fourth-year-medical student, called an ambulance.

Wrexham Maelor Hospital

She was taken to Wrexham Maelor Hospital, but with ambulances queuing outside she remained in the ambulance for almost three hours. Sophie and the paramedics suspected she had sepsis she was not triaged and paramedics were not permitted to administer antibiotics while she was in the ambulance.

Independent expert Professor Solomon Almond told the inquest, however, that Miss Brousas, who had been very fit, was”destined to die”.

He said she would have had a 51 per cent chance of survival had she had antibiotics before noon on the day she was taken to hospital, so the wait outside the hospital was not significant.

In issuing a narrative conclusion, Mrs Lees said that although there were “clear failings”,including the failure by the ambulance crew to pre-alert the hospital and for triage to be carried out, she was not satisfied, in view of Professor Almond’s evidence, that they played a part in her death.

Mrs Lees said she would not be issuing a Regulation 28 notice to prevent future deaths against the Health Board because of improvements which have been made, but would do so against the ambulance service.

She was concerned, she said, about the pre-alert policy, the paramedics being unable to administer antibiotics in the ambulance and the absence of any policy to escalate matters for patients waiting in ambulances.

After the hearing Miss Brousas’ partner Simon Goacher and her daughter Sophie said they had no faith in the Health Board to make improvements and called for chief executive to stand down.

“We have heard details throughout the inquest of a complete breakdown in the care Sam should have received. We all out our trust in the healthcare professionals to provide Sam with the best treatment and we feel that she was let down in the worst possible way,” they said.

All the professionals who came into contact with Sam recognised that she had sepsis and needed antibiotics but she was kept in the ambulance without receiving the necessary treatment.

The family’s solicitor Stephen Jones said the evidence heard during the course of the inquest had been “truly shocking” and witnesses had described the situation as”chaotic”.

“This was by no means the first time that this hospital had faced this situation,” he said. “Indeed, this coroner’s court has previously made prevention of future deaths reports identifying this very risk when patients cannot be offloaded promptly from ambulances and admitted to the emergency department.

“Unless the situation changes patient safety will inevitably be compromised, and Sam’s family urge the Best Cadwaladr University Health Board and the Welsh Ambulance Trust to work together to address the systemic failings identified at the inquest and out patient safety at the absolute top of their agenda.”

Mr Jones said they were disappointed that no Regulation 28 report was being issued to the Health Board but that legal action was being taken. “We believe there are valid grounds for action against them,” he added.

The ambulance service and health board promise to work to prevent the risk of such an incident happening again, although no indication of neglect was made against the health board in the coroner's verdict.

Dr Brendan Lloyd, executive director of medical and clinical services and deputy chief executive at the Welsh Ambulance Service, said: “Our ambulance service exists to preserve life so it was with a heavy heart that we learned of the death of Miss Brousas and we extend our deepest condolences to her family.

“There are clearly lessons to be learned from this case for both us and our colleagues at Betsi Cadwaladr University Health Board, which is why we have been working with them in earnest to reduce the risk of this happening again in future.

“We have taken a number of steps to improve patient safety following the death of Miss Brousas, including advice for our paramedics about when to pre-alert a hospital to a patient’s condition.

“Supporting our health board colleagues to reduce handover delays at hospitals remains a priority, and it is encouraging that there has been a significant improvement at Wrexham Maelor Hospital this year compared to last.

“That said, we absolutely recognise that there is more we need to do in order to fulfil our vision of becoming a leading ambulance service providing the best possible care.

“We accept the conclusions of the Coroner and would once again extend our thoughts and sympathies to the family of Miss Brousas.”

Mrs Lees said she be issuing a Regulation 28 notice to prevent future deaths against the Welsh Ambulance Service, but not the health board because of improvements that have been made.

A spokesman for Betsi Cadwaladr University Health Board said: “We fully accept the coroner’s verdict today and we would like to extend our deepest condolences to Miss Brousas’s family.

“We know that lessons must be learnt. Over the past 18 months we have worked with our partners in the ambulance service to improve the way patients are transferred when they arrive at hospital. This has already brought about significant improvements for patients and our staff who care for them, but we know there is more to do."