Maureen Owens

I am John Adrian Gittins, Senior Coroner for North Wales (East and Central)

On the 15th of August 2023 I commenced an investigation into the death of Maureen Elizabeth Owens (DOB 28.2.43 DOD 9.12.22). The investigation concluded at the end of the inquest on the 20th of March 2024. The cause of death was recorded as being due to 1(a) Multiorgan Failure 1(b) Bilateral Femoral Thrombosis (operated) 1(c) Peripheral and Central Vascular Disease and the conclusion of the inquest was by way of a narrative in the following terms : The death was due to natural causes, contributed to by operational delays as a result of which the deceased was not afforded the timely care and treatment which may have optimised the prospects of a full recovery

On the 6th of December 2022, whilst a patient at the Maelor Hospital Wrexham, the deceased developed a condition which required urgent vascular surgery, however her transfer for this procedure was delayed and despite subsequent surgical intervention, she deteriorated post-operatively and died at Glan Clwyd Hospital on the 9th of December 2022.

During the course of the inquest the evidence revealed the following matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. An investigation by the Health Board indicated that the transport request for urgent transfer for vascular surgery should have been booked by the ward with the Adult Critical Care Service Cymru (ACCTS) and not WAST and evidence was received in the course of the inquest which suggests that there is inadequate knowledge of the use of ACCTS and its operation across the whole of the Health Board, including clinical site managers as well as clinicians and nursing staff.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action