THE traumatic end of life care experienced by a British Empire Medal recipient at Ysbyty Glan Clwyd should never happen to anyone else.

That is what his daughter, Geraldine Smith, told the health board after it told her lessons had been learned from a review into his treatment.

William Oswald Jones, a retired caretaker at Ysgol Mair in Rhyl who was born in Wrexham, died on June 19 last year at the hospital after suffering a fall that April.

The inquest into Mr Jones death had been adjourned to allow Betsi Cadwalader University Health Board (BCUHB) to answer a number of questions raised by the 91-year-old’s family about issues with his care they believe may have contributed to his death.

The inquest was resumed yesterday (March 3) at Ruthin’s County Hall by Assistant Coroner for North Wales David Lewis.

During the inquest, Mr Lewis gave Mrs Smith “latitude” to voice her family’s concerns that would not normally fall under the remit of his court because, although the health board’s representative and Mr Lewis accepted mistakes and communication errors made during the last weeks of Mr Jones’ life must, and are, being learnt from, they did not directly contribute to his death.

This included him being returned to the Emergency Department at Glan Clwyd, where he endured a 13 hour wait on a trolley, not long after he had been transferred to Ruthin Community Hospital.

Mrs Smith said: “The main reason I’ve put myself through this, and for me it has been hard, is that the outcome of this will make sure that no other family will have to go through this again.”

To BCUHBoard and Ysbyty Glan Clwyd, she said: “I’m not asking you, I’m telling you. These people deserve to go though end of life care with dignity, pride and care.”

Mrs Smith said she and family members were left with Mr Jones for long periods and she felt he was not given enough nutrients, hydration and pain relief to make his last days more bearable and dignified.

She added: “Nobody helped me. I had all of those years with him and they are precious. But he did not die peacefully.”

Mr Jones, of Rhyl, was admitted to hospital in April after suffering a fall. One of the family’s concerns was that he was treated as if he had suffered a stroke rather than a subdural haemorrhage, which CT scans had confirmed.

Mrs Smith added: “When my dad came in to hospital after the fall he was walking. Right from the beginning the doctors new it wasn’t a stroke it was a haemorrhage.

“He was told that when he could walk from his bed to the toilet, he could go home on Friday which was what he desperately wanted.”

She described being taken into a room to be told by a senior nurse that her father had suffered a second stroke, and that she believed being treated for a stroke “just to clear the ward and get him home by Friday” resulted in his condition deteriorating.

“After that episode he was unable to eat, swallow, get out of bed or even lift his covers.”

Linzi Shone, head of nursing medical directorate at BCUHB, said Mr Jones’ treatment was for a haemorrhage and not a stroke, and this was an example of several cases of miscommunication between medical staff between themselves and with the family that occurred during his care.

These also included him “slipping through the system” and not being referred to the dietetics department because another patient had a similar name, not having a treatment escalation plan in place, and information such as him having bed sores and a stoma not being communicated each time he was moved to a different hospital.

While accepting miscommunication and mistakes had taken place, such as the 13 hour wait on a trolley when he was readmitted to Glan Clwyd’s A&E, Mr Lewis said he was satisfied these had not impacted on the cause of Mr Jones’ death.

Mr Lewis said: “Had he been spared that experience would the outcome have been any different?”

Ms Shone, who chaired the review into Mr Jones’ treatment at Glan Clwyd and Ruthin Community Hospital, replied: “It is my understanding that the outcome would not have been any different.”

She extended an offer to meet with Mrs Smith and her family to discuss any issues further.

But she told the inquest: “As head of nursing I am satisfied that there aren’t any persistent failings and this isn’t the tip of the iceberg.”

Tearfully recalling her own grandfather’s end of life care, she added: “The standard of care that he received is what I aspire for all patients to receive.”

She said several changes had been made at the hospital, issues flagged up, and more conversations were due to take place. For example, three full days of end of life care training had been scheduled for all relevant staff.

Mrs Smith told the inquest her father had received the British Empire Medal for services to the community in Rhyl and, rather than go to Buckingham Palace, he asked to received his honour at Ysgol Mair so the children could experience it.

Mr Lewis agreed that the cause of Mr Jones’ death in June 2019 was a result of bronco pneumonia caused by a traumatic subdural haemorrhage resulting from a fall.

Recording a conclusion of accidental death, he told Mrs Smith: “A lot of what you are saying touches all of us.

"It doesn’t matter how old they are, they are your mum and dad.”