22-04-2025
Report issued by coroner after death of Flintshire pensioner
John Gittins, Senior Coroner for North Wales East and Central, expressed concern about the situation following the death of a Mold pensioner.
Patricia Ann Catterall, 81, had been a patient at Mold Community Hospital for 207 days before being transferred to the Cae Bryn Nursing Home, part of the Pendine Park care organisation, in Wrexham on June 11, 2024.
Her condition deteriorated and on June 19 she was admitted to the Maelor Hospital where she was diagnosed as suffering from Hyperosmolar Hyperglycaemic Syndrome (HHS) – very high blood sugar levels – and sepsis.
Her condition and co-morbidities meant she was unfit for aggressive treatment and she died on June 23.
An inquest heard that whilst in hospital Mrs Catterall's blood sugar levels were checked three times a day in hospital in Mold but only once a day at the nursing home.
In a Prevention of Future Deaths sent to the Pendine Park organisation and the Betsi Cadwaladr University Health Board, the Coroner said: 'The process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had not been received and assessed prior to the patient being received into their care.
'Evidence was received that in the majority of cases (post Covid) there are no face-to-face assessments prior to patient transfer and that the assessment is therefore dependent on the documentation supplied to the Nursing Home by the Health Board, which in some cases may result in not all relevant information being provided.
'In this instance evidence was given that the Nursing Home did not know that the deceased's blood sugar levels were monitored three times per day whilst in the care of the Health Board.'
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A spokesperson for the Cae Bryn nursing home said: 'It is clearly vitally important that a nursing home is given full and detailed information about a patient's needs when they are discharged from hospital and we will convey to the Coroner that we would support a tightening up of the handover procedure to ensure that hospitals pass on all the relevant information to the home so that the appropriate level of care can be provided.'
Angela Wood, Executive Director of Nursing & Midwifery at Betsi Cadwaladr University Health Board, said: 'I would like to offer my heartfelt condolences to the family for their loss.
'We are continually working to improve our services, and we will be responding to the coroner directly outlining the actions that we are taking.'
The home owners and Health Board have until June 6 to respond, either explaining what steps have been taken to address the Coroner's concerns or why it is felt that no action is necessary.
