Bernard Phillips was taken by ambulance to Withybush General Hospital on March 25, 2024, following a fall at his care home.
Pembrokeshire Coroner Gareth Lewis heard that the A&E Department was ‘extremely busy’ that night and Mr Phillips had to remain outside in an ambulance for about 12 hours.
An inquest has been held into the death of a man at Withybush Hospital, pictured (Image: Hywel Dda University Health Board)
The following morning, he was transferred by trolley into the A&E department. Mr Phillips remained in A&E on that trolley for a further two days before being transferred to Ward 12 on March 30.
The inquest heard that Mr Phillips spent a prolonged period of time on the trolley without the benefit of a pressure relieving mattress.
During that time ‘insufficient skin checks’ were undertaken and a developing pressure sore on his sacrum was incorrectly recorded by nursing staff.
These factors led to Mr Phillips developing a substantial Suspected Deep Tissue Injury (SDTI).
However, even after the SDTI had been documented by the senior sister in the A&E department on March 27, the skin checks and recording of the pressure sore on the sacrum continued to be incorrectly undertaken or noted.
Mr Phillips was left on a trolley for two days in Withybush Hospital’s A&E department. (Image: Google)
Once he was moved to ward 12, Mr Phillips was provided with appropriate care. He was given antibiotics and initially rallied but eventually succumbed to the effects of sepsis April 29, 2024.
A postmortem gave the primary causes of his death as sepsis, aspiration pneumonia and sacral pressure sores.
Other causes were recorded as frailty of old age and chronic small vessel cerebrovascular disease.
The coroner concluded that the circumstances that led up to Mr Phillips’ death were avoidable. (Image: Newsquest)
Pembrokeshire Coroner Gareth Lewis said: “The pressure damage to Mr Phillips’ sacrum on or around March 26, 2024, was, on the balance of probabilities, avoidable.
“Furthermore, but for the development of the pressure damage, on the balance of probabilities, the infections he suffered would not have developed and his death on April 29, 2024, would likely have been avoided.
He concluded: “Bernard Phillips died in circumstances where he developed sepsis as a result of avoidable pressure sores which were caused during a prolonged delay in the A&E Department at Withybush General Hospital in the absence of sufficient skin checks, the use of a pressure relieving mattress and the condition of his developing pressure sore on his sacrum not being correctly recorded by nursing staff.”
The Western Telegraph has contacted Hywel Dda Health Board for comment.
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