Patient died after nurse discharged him from hospital

AMAN died the day after he was sent home from hospital by a nurse practitioner who believed he had anxiety.

Simon Willans, 42, was in fact suffering from a clot on his lung (pulmonary embolism) and had been sent to Ysbyty Gwynedd, Bangor, by his GP.

Mr Willans, from Ty Groes, Anglesey, hadn’t been examined or had his notes looked at by a consultant before discharge.

The misdiagnosis was the subject of a police investigation into a possible offence of gross negligence manslaughter but a decision was made by the Crown Prosecution Service not to pursue a criminal case.

Now, assistant coroner for north Wales Nicola Jones has issued a prevention of future deaths notice due to her concerns that this could occur again unless Betsi Cadwaladr University Health Board makes changes.

In the notice, Mrs Jones said: “Mr Willans’ GP telephoned Ysbyty Gwynedd on 25 January, 2016, to try to have Mr Willans admitted as an urgent case.

“Mr Willans was admitted the next day to the ambulatory care unit at Ysbyty Gwynedd.”

He was seen by an unnamed nurse practitioner who listed “orthostatic hypotension, viral illness, hyperthyroid and deep vein thrombosis/pulmonary embolism” as possible causes, Mrs Jones said.

Blood tests indicated the possibility of a serious blood clot, while an ECG taken of his heart was abnormal.

Mrs Jones said the ECG was dismissed because there was a reference in the notes that in 2009 this had been attributed to anxiety, however, she said the GP had already said the patient’s symptoms were not due to anxiety.

His right calf was swollen some 3.5 centimetres more than the left and he had complained of being breathless and had suffered a “recent loss of consciousness”, the assistant coroner added.

An ultrasound was taken but did not “image” the swollen calf, and blood gases were found to be abnormal.

Mrs Jones said the patient’s mother had had a pulmonary embolism but this information was not secured from the patient when the nurse was taking his history.

He was discharged after being diagnosed with anxiety and orthostatic hypotension – a drop in blood pressure when standing up.

A letter was sent to his GP recommending he be given betablockers. Mr Willans died on the day the letter was sent out.

“My inquiries revealed matters giving rise to concern,” Mrs Jones said. “In my opinion there is a risk that future deaths will occur unless action is taken.”

She said she was concerned a serious incident review had only recently been started by the health board, and that the ambulatory care unit, its structure, practices, systems and staff have not been effectively scrutinised since.

She also raised concerns that there was no evidence of the consultant at the unit examining Mr Willans or looking at his results, that Mr Willans appears to have been discharged by a nurse with no involvement in the case, and that no other doctors appeared involved in his discharge.

Mrs Jones said she was also concerned not enough information was given to Mr Willans if his condition deteriorated, the history taken was inadequate and that an anticoagulant, which helps prevent the formation of clots, was not administered.

An inquest is yet to be held into Mr Willans’ death.

The health board declined to comment on the coroner’s notice.