Coroner identifies “suboptimal” care for stroke patient

A coroner has determined that an 80-year-old woman, who passed away following a stroke, was provided with “suboptimal” care at the mental health facility where she was undergoing treatment. Janet Saxon had been admitted to the Tawel Fan ward, located at Ysbyty Glan Clwyd in Denbighshire, five months prior to its closure in 2013 due to accusations of patient mistreatment. During an inquest held in Ruthin on Wednesday, Coroner David Lewis stated that it remained uncertain whether the quality of care she received contributed to her death. The Betsi Cadwaladr health board has issued an apology and affirmed its commitment to continuously improving care standards. Mrs. Saxon, a resident of Prestatyn, Denbighshire, was admitted to the hospital in early July 2013 for depression and anxiety, and was discovered on the ward on July 15, having experienced a stroke. Subsequently, she was moved to intensive care, where her death occurred. She presented with several pre-existing medical conditions, such as diabetes, which elevated her susceptibility to a stroke. Mr. Lewis commented that the inadequate standard of record keeping would have come as “no surprise” to anyone present in court. He further explained, “An incomplete picture was available to court and experts cannot say how her condition changed between admission and the stroke.” In delivering a narrative conclusion, Mr. Lewis stated that both the standard of care provided and its documentation “fell below what was regarded as acceptable, but it is not clear to me that departure from standards made a difference to [the] outcome.” He concluded, “Janet Saxon died as result of a stroke whilst on Tawel Fan ward.” He added, “The evidence disclosed suboptimal care and treatment, but it did not reveal whether it affected the outcome.” Following the inquest, Mrs. Saxon’s daughter, Tina Cox, expressed that she and her family felt they were “in limbo.” She remarked, “I know there was lack of care, but nothing’s been done about it.” Cox continued, “I was hoping for closure today, but I don’t think it ever will be closed.” She further stated, “We’ve always said a public inquiry is needed, because it’s been a big scandal.” “I think eventually it will come out,” she concluded. Dr. Sree Andole, who serves as Betsi Cadwaladr’s interim executive medical director, conveyed his “thoughts and heartfelt condolences” to Janet Saxon’s family. He stated, “We accept the coroner’s findings unreservedly and I would like to apologise on behalf of the health board for those elements of Janet’s care which fell below the standards she deserved.” He also mentioned that the health board is committed to “keep raising the standards of care” for its patients.