GWENT’S health board has admitted breaching its duty of care to a critically ill woman - who subsequently died at Nevill Hall Hospital - after treatment for a dangerous diabetic condition was delayed for an hour.

Thirty-eight year-old Lisa Jane Howells suffered two heart attacks whilst on a trolley in the hospital’s busy A&E department on Sunday April 27 last year, as doctors began that treatment.

A damning preliminary report highlighting the key findings of an internal investigation started just days after her admission, but only now made available to her family, concludes “there was significant delay in the triaging and initiating treatment of Ms Howell’s condition.”

Aneurin Bevan University Health Board chief executive Judith Paget offers her “sincere and wholehearted apology for this delay” in the report, which describes it as being caused by three factors:

• Delay in identifying Ms Howells as a sick patient;

• Lack of escalation/communication regarding her condition;

• Problems caused by variation in staffing levels and issues with patient flow in the hospital and department.

The latter, says the report, meant queues built up “going out into a back corridor and out of sight of staff.”

It concludes that Ms Howells, a mother-of-two who also had four step-children, should have been triaged within 10 minutes of arrival, after which she would have been seen by a consultant, a diagnosis of diabetic ketoacidosis made, and treatment started 55 minutes earlier.

Ms Howells died at Nevill Hall on May 15, by which time the health board was two weeks into an internal investigation.

Her father Graham Howells, of Usk, received an apology from a consultant over the treatment delay on May 1, and was told of the investigation.

But he had to wait almost 10 months to receive its conclusions, and those of a health board redress panel, set up due to the seriousness of the matters investigated.

He told the Argus two weeks ago of his disgust at the wait for the report, and he remains disgusted, this time at the delay in his daughter’s treatment.

“It’s a bit of a weight off my shoulders, knowing what happened, because my grandchildren (Jordan, aged 19, and 17-year-old Jade) wanted answers and I didn’t have them,” he said.

“Now at least we have this, and an admission things went wrong, but it’s disgusting something like this should happen.

“It was terrible, losing her like that, and nothing will bring her back.”

The report states the redress panel “confirmed that the health board had breached its duty of care (to Ms Howells)... when there was a failure to triage her in a timely way.”

The panel considered the issue of ‘harm caused’ through that failure, but was “unable to confirm what would have happened... had the treatment commenced on admission.”

This must be investigated separately, and may raise issues of potential liability and damages.

A heartbroken Mr Howells meanwhile, is convinced more immediate action would have resulted in a better outcome.

“If they had taken her straight into intensive care, and put her on kidney dialysis to get the toxins out, I’m positive she would have been here today,” he said.

An Aneurin Bevan Health Board spokeswoman said today: “We wish offer our sincere apologies that the Health Board breached our duty of care to Lisa Howells in May 2014. Following a detailed internal investigation our Redress Panel confirmed that there was a failure to assess her condition in a timely way, and we fully accept that the standard of care given to Lisa fell short of what we would have expected and should have been delivered. We would like to offer again our unreserved apologies to Lisa’s family for this failing in our care.”

 

 

LISA Jane Howells lived with Type One diabetes for around 15 years, and had been in and out of hospital.

She became ill and started vomiting at home in Gwernesney on April 26 last year and, having worsened overnight, an ambulance was called.

Given morphine for her pain by paramedics who diagnosed a diabetic hyperglycaemic episode, she was taken to Nevill Hall, arriving at 1.10pm and being booked in at 1.20pm.

“Unfortunately at that time the department was extremely busy and Ms Howells had to wait on a trolley in the corridor to be seen,” states the health board’s report.

She was given more morphine at 1.25pm, but no further observations were made until 2.27pm, when she was triaged.

“She was given a triage category of three (to be seen within an hour). However (Ms Howells)... was also seen by the nurse in charge who noted that she looked extremely pale and unwell,” states the report.

On Ms Howells telling the nurse she had diabetes, her blood sugar levels were measured and found to be high. Diabetic ketoacidosis was suspected and she was moved to the resuscitation area, a consultant was informed, and the triage category upped to two (to be seen within 10 minutes).

Found by the consultant to be “drowsy and confused” she was diagnosed with diabetic ketoacidosis. This occurs when diabetes patients suffer consistently high blood glucose levels, caused by a severe lack of insulin.

The body, thus unable to use glucose for energy, begins to break down other tissue for energy, producing toxic ketones as a by-product. If not dealt with, they cause the body to become acidic.

As treatment began on a developing heart problem caused by high potassium levels, Ms Howells went into cardiac arrest and though resuscitated, suffered a second arrest shortly afterwards.

In the intensive care unit, a scan subsequently indicated a brain injury due to the cardiac arrests. She developed pneumonia, suffered another cardiac arrest on May 15, and died later that day.