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Family tell inquest of concerns after Timothy Cowen's post-op death | Family tell inquest of concerns after Timothy Cowen's post-op death |
(about 4 hours later) | |
The brother of a disabled man who died after a routine operation has told an inquest his death should never have happened. | The brother of a disabled man who died after a routine operation has told an inquest his death should never have happened. |
Timothy Cowen, 51, died after a gall bladder operation at Wrexham Maelor Hospital in May last year. | Timothy Cowen, 51, died after a gall bladder operation at Wrexham Maelor Hospital in May last year. |
The inquest in Mold was told there was a lack of communication about his care. | |
The coroner, recording a narrative verdict, said lessons had undoubtedly been learned, but he was still concerned about training. | |
John Gittins said there should be mandatory training for all staff working with patients with learning difficulties. | |
Mr Cowen's brother Philip had told the inquest earlier that the hearing was "not about blame, but about finding out what happened". | |
"This should have been a never-event. Procedures should have been put in place and followed," he said. | |
'No observations taken' | 'No observations taken' |
Philip Cowen said his brother, who had severe learning difficulties and had to be fed via a tube through his stomach, was "a bubbly and happy person". | Philip Cowen said his brother, who had severe learning difficulties and had to be fed via a tube through his stomach, was "a bubbly and happy person". |
He told the coroner, John Gittins, that on the day Mr Cowen from Caergwrle, Flintshire, was due be discharged no observations had been taken all day. | He told the coroner, John Gittins, that on the day Mr Cowen from Caergwrle, Flintshire, was due be discharged no observations had been taken all day. |
Earlier, Mr Cowen's mother, Berenice, told the inquest staff had tried to feed him through the tube while he was lying down on two occasions. | Earlier, Mr Cowen's mother, Berenice, told the inquest staff had tried to feed him through the tube while he was lying down on two occasions. |
However, his notes stipulated he should only be fed sitting up because of the risk of reflux and pneumonia. | However, his notes stipulated he should only be fed sitting up because of the risk of reflux and pneumonia. |
Spot audits | Spot audits |
Fleming Ward sister Janet Edwards told the hearing staff were used to caring for patients who were tube-fed into their stomachs and she was "confident" staff were aware they needed to be at a 45 degree angle and would never feed patients lying flat. | |
She said carers who had visited Mr Cowen may have been concerned he was being fed in bed when they would usually feed him sitting in a chair. | |
"We were still feeding him in the correct position," she said. | "We were still feeding him in the correct position," she said. |
Responding to the fact that Mr Cowen's observations were taken at 08:00 BST on the day of his discharge, she said that should not have happened and observations should have been noted more regularly. | Responding to the fact that Mr Cowen's observations were taken at 08:00 BST on the day of his discharge, she said that should not have happened and observations should have been noted more regularly. |
But she said that since his death, improvements had been made with spot audits held. | But she said that since his death, improvements had been made with spot audits held. |
Nesta York, who was the project manager of Y Maes, the care home where Mr Cowen lived, told the inquest she had concerns about his feeding on a visit to the hospital the day after his operation. | |
After the hearing, Betsi Cadwaladr health board apologised for "the range of clinical and service errors which occurred during Mr Cowden's stay at the Wrexham Maelor Hospital in 2013". | |
Angela Hopkins, executive director of nursing and midwifery, added: "A detailed investigation was undertaken with the involvement of the family and a comprehensive action plan and range of recommendations developed. | |
"These included ongoing training for staff to ensure that standards are met and maintained and this is being closely monitored." |