Coroner Finds Missed Transfer Opportunities Before Woman’s Death After Private Operation

A coroner has concluded that three distinct opportunities were overlooked to transfer a 79-year-old woman to an emergency unit after complications arose following hip surgery at a private hospital. Gwynneth Exall, from Swansea, suffered a cardiac arrest and died on April 28, 2022, one day after undergoing a hip replacement procedure at Nuffield Health Vale Hospital. In her narrative conclusion, Coroner Patricia Morgan stated there was “a lack of escalation and timely treatment which impacted her prospects of surviving a cardiac event”. She identified three instances where an ambulance should have been called to transport Mrs. Exall to the University Hospital of Wales in Cardiff, which would have provided her a “greater prospect of survival”. The first of these occasions was at 08:00 on the morning of April 28. An ambulance was eventually summoned at approximately 16:00. Gwynneth Exall had opted for private treatment to avoid the waiting list for an operation on the NHS. The inquest, held in Pontypridd on Wednesday, heard that her blood pressure and urine levels were low following the surgery on April 27, before her condition worsened the subsequent day. According to evidence presented during the inquest, the private hospital lacked the facilities to manage acutely ill patients, including the rapid deterioration in Mrs. Exall’s condition and cardiac arrest. The coroner also determined that there were “insufficient on-site consultants” at the hospital, leading nursing staff to feel unable to escalate the situation and call an ambulance without first consulting a consultant. Ms. Morgan found that telephone consultations with doctors regarding Mrs. Exall’s condition were “not sufficient,” advocating for in-person consultations instead. Dr. Mark Raper, an intensive care consultant at the University Hospital of Wales, informed the inquest that Mrs. Exall should have been transported by ambulance to intensive care at another hospital several hours earlier than she was. He stated that if she had been transferred sooner, “on the balance of probability her mortality risk would be lower”. He told the coroner that it would have been “entirely appropriate” to call an ambulance at 08:00 rather than later in the afternoon. In a statement, Mrs. Exall’s son David reported that the paramedics shouted at the staff in the private hospital, being “frustrated at their inaction”. Professor Richard Attanoos, the pathologist who performed the post-mortem examination, concluded that Mrs. Exall “would not have died when she died had she not had surgery”. The inquest heard that some observations of Mrs. Exall’s blood pressure had been recorded on paper and not entered into the hospital’s computer system, making them inaccessible to clinicians making decisions about her treatment. The coroner was assured that these issues had since been addressed, and observations should now be directly inputted into the computer system as they are taken, with paper records used “very rarely”. Nuffield Health issued a statement expressing that it was “deeply saddened by the passing of Mrs Exall”. The organization added, “Our thoughts remain with the patient’s family.” It further stated, “Our priority is patient safety and delivering the highest quality of care to our patients.”