A coroner has launched a stinging attack on hospital managers for delaying changes aimed at helping to save lives.

Speaking at an inquest into the death of a Flint man who died at Glan Clwyd Hospital after taking a massive overdose of paracetamol, John Gittins, chief coroner for North Wales East and Central, said he was ”more than frustrated” to learn that promised deadlines had not been met.

“The staff on the ground do everything they possibly can to the best of their abilities in unbelievably difficult circumstances but the support is sometimes lacking at managerial level. Time and time again I am left more than frustrated by their inability to act on what I am being told.

“That is not good enough and that is no reflection on the work of the clinical staff.

“There are lives being put at risk by this Health Board not implementing what they said they would do in a timely manner.”

In July Mr Gittins issued a Regulation 28 Prevention of Future Deaths report to the Betsi Cadwaladr University Health Board at an inquest into the death of 50-year-old Rhian Roberts who also died after taking a high level of paracetamol.

At that time he was told by Gill Harris, the Board’s executive director of nursing, said that new procedures to speed up the diagnosis and communicating of life-threatening blood results would be in place by October 1.

But at today’s inquest he was told by Dr Tom O’Driscoll, consultant in emergency medicine, that it was now hoped to be implemented by Christmas after receiving formal approval.

Dr O’Driscoll also told the inquest that although it was already possible for an antidote for a drugs overdose to be administered based on a suspected overdose it had not yet been adopted by the Board, and he agreed with the coroner that junior doctors might be reluctant to step outside the recognised protocol.

The inquest heard that Kyle Hurst, 29, from Havana Flats, Flint, was found in a car near Flint Mountain on January 24 and he told ambulance crew the number of paracetamol tablets he had taken as well as other drugs.

The ambulance had to queue outside the emergency department for about three hours but triage nurse Rosalind Goodall said that Mr Hurst’s observations were normal, though he would not say when he had taken the drugs.

When he was finally admitted he vomited and his condition deteriorated before he died later the same day.

The inquest was told that Mr Hurst, who suffered from ADHD, had taken a previous overdose.

His mother, Anita Craig, said he struggled with his condition and before Christmas had lost his job and accommodation, and also been banned from driving.

“He sadly felt he had lost everything and took his own life,” she said.

Dr O’Driscoll said that he would have preferred had the antidote been given on the basis that he had taken such a large overdose instead of waiting for the test results but the level pf toxicity was so high it might not have made a difference.

Mr Hurst, a builder, died of multi- organ failure and the coroner recorded a conclusion of suicide.

He issued another Regulation 28 report raising concern about the failure to keep the October 1 deadline and why the accelerated administering of the antidote was not yet an official protocol.

Mr Gittins said he accepted that the Board faced huge challenges in supporting staff and patients, but added: “I am more than frustrated at having to make comments but when I am told that certain things are going to be done and they are not done that is not acceptable.”

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