A PATIENT with a dangerous diabetic condition, who later died, endured unacceptable triage and treatment delays after arriving at a Gwent hospital, a report concludes.

Aneurin Bevan University Health Board has already admitted breaching its duty of care to 38-year-old Lisa Jane Howells at the A&E department at Nevill Hall Hospital, Abergavenny, in April last year.

Ms Howells, a mother-of-two who also had four step-children, and was living in Gwernesney, waited more than an hour to be triaged after registration at 1.20pm on Sunday April 27 2014.

And a health board serious concern report revealed she was then given a triage categorisation of three, meaning she could have waited up to another hour to be seen, had not the nurse in charge noticed how unwell she looked.

Ms Howells told her she had diabetes and after blood sugar levels were measured, she was moved to the resuscitation area, as potentially fatal diabetic ketoacidosis was suspected.

Her triage category was changed to two (to be seen within 10 minutes) and an A&E consultant noted her worsening condition. During treatment, she suffered two cardiac arrests and was transferred to intensive care.

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.

The serious concern report stresses a difficulty in judging how much effect the delays had in the cause of the cardiac arrest and states: "It is uncertain if the outcome would have been altered if the treatment had been delivered on arrival to hospital."

Nevertheless, it concludes: "There was an unacceptable delay in triage and initiating treatment to Ms Howells in the emergency department."

Ms Howells' father Graham, who lives in Usk, and her teenage children Jordan and Jade, waited almost 10 months, as previously reported by the Argus, for the initial findings of an internal investigation started just three days after she arrived at Nevill Hall.

Having now received the serious concerns report, the case remains with solicitors, and Mr Howells said any financial settlement would benefit the children.

"But they'd much rather have their mum, and I'd rather have my daughter back," he said.

"From the minute she arrived in hospital this has been a nightmare, and there are lots of unanswered questions.

"For instance, an ECG (electrocardiogram) done by the ambulance crew has been mislaid. Why?

"There's nothing in here (the report) to give us any comfort. I've said what happened was disgusting, and that's still how I feel, disgusted."

The report considers issues such as lack of identification of a sick patient, and lack of escalation. It states that the ambulance crew told nursing staff Ms Howells had been in a corridor for a "protracted" period of time, but the investigation proved unable to identify these staff.

It also highlights issues with department staff numbers during shifts, and with the skill mix on that shift. More than half of those on duty had been there less than a year, and not all had what is deemed an emergency department skill set.

It also reveals that there was not always a nurse allocated to patients waiting in the corridor.

A hard-hitting Healthcare Inspectorate Wales (HIW) report issued in March concluded that patient care at Nevill Hall's emergency department was adversely affected at times during an unannounced inspection last December, due to demand and the physical environment.

The situation was most difficult in the unit's corridors, described as "unacceptable" for treatment and care.

It also revealed that a Rapid Assessment Team for patients had been introduced following "an incident", a reference to Ms Howells' case.

The health board has previously apologised to Ms Howells' family and stated that "we fully accept that the standard of care fell short of what we would have expected and should have been delivered."

A spokesman for the Welsh Ambulance Services NHS Trust, which supported the health board in its investigation, said: “We would like to extend our thoughts and deepest sympathies to the family of Ms Howell following their tragic loss.

“If they have any outstanding questions or concerns, we would be more than happy to meet them and discuss events in more detail."