Pembroke woman died at Withybush Hospital after waiting hours for scan

Ruth Cole, was taken ill at the Pembroke home that she shared with her husband, Roy Pope, on the morning of May 16 2022.

The former carer thought initially that her symptoms may have been caused by a hiatus hernia.

However, as the chest pain continued accompanied by a sharp pain between her shoulders, nausea and collapse an ambulance was called and Mrs Cole was given priority status due to her symptoms.

Initial consideration was given to a transfer to the cardiac unit at Morriston Hospital. However, it was decided that Mrs Cole would be best treated at Withybush Hospital and she was taken there, arriving at 1.45pm.

At Withybush she was put in the resuscitation area which at that time had a ratio of one nurse to four patients.

During her time in resus another patient suffered a cardiac arrest and was blue lighted to Morriston.

Mrs Cole was initially diagnosed with sepsis and treated with antibiotics.

A CT scan was ordered. However, Mrs Cole was not taken for this scan until hours later.

Pembrokeshire Coroner, Paul Bennett, said that the reasons for the delay in the scan were ‘hard to establish’.

A site report issued that day said that there were problems with the CT scanner and that it was unavailable but the source of that information remained unclear.

Two radiologists who gave evidence at Mrs Coles’ inquest both said that the scanner was working and had been used that day.

The inquest heard that Mrs Cole had come into hospital with a high NEWS (National Early Warning Score). Her score had not gone down with treatment but instead was increasing.

Nurse Dyer a senior emergency department nurse who investigated Mrs Cole’s death for the health board said that Mrs Cole came in with a NEWS Score of 9 and that increased to 11 within one and a half hours.

“Within two hours a call should have been put into the medical emergency team that she was critically ill. She needed the critical care outreach team. Unfortunately that didn’t happen for several hours,” she said.

She added that ‘the body could only take so much’ when a high NEWS score continued or increased.

“Mrs Cole should have had more attention,” she said.

The inquest heard that procedures and staffing levels had changed at Withybush Hospital following Mrs Cole’s death.

After her scan had been performed it had to go to an external company for assessment who said that the scan showed Mrs Cole had had an ascending aortic aneurysm.

It was then decided to transfer Mrs Cole to Morriston, but before this could be done, she suffered a cardiac arrest and died at 3.50am on May 17.

Independent expert Dr John Heyworth told the inquest that some of Mrs Coles symptoms were characteristic of an ascending aortic aneurysm. He also said the time that it took Mrs Cole to have a CT scan was of concern.

Another independent expert Mr Lall said had Mrs Cole got to theatre in Morriston Hospital by 3am on May 17, she would have had a 75 to 90 percent chance of surviving the surgery and would have had a 50 percent prospect of survival after five years.

Had Mrs Cole been diagnosed earlier and taken to Morriston sooner there could have been a successful outcome.

Pembrokeshire Coroner Paul Bennett said: "In light of the expert evidence, it cannot be said that there was an inevitable fatal outcome from the presence of the ascending aortic aneurysm. A timely diagnosis and transfer may well have affected the position.

Mr Bennett concluded: “Ruth Susan Cole died from complications as a result of an ascending aortic aneurysm which went untreated following delayed diagnosis and which had it been treated would have affected the outcome.”

Mrs Cole’s husband, Roy Pope, told the inquest: “That sad day should never have happened. She went into hospital. All the signs were indicating that she was getting worse. There was no intervention. Something should have happened earlier. She should never have got to that point.”