A MAN with severe learning difficulties died at Morriston Hospital following a failure of appropriate medical attention, an inquest has concluded.
Paul Ridd was admitted to the hospital on New Year's Eve 2008, for an operation on a perforated bowel, but had been moved into the hospital's intensive therapy unit (ITU).
The 53-year-old, who had undergone a tracheostomy, [corr] died three weeks later after being moved back onto Ward G due to secretions on his lungs which caused respiratory problems.
The inquest into his death at Swansea Civic Centre heard that there had been a series of failures, including a failure of communication between the ITU and Ward G for regular suctioning to be carried out to clear secretions which had built up in his throat.
In the days before his death, it had been calculated it would been expected that Mr Ridd should receive between 11 and 15 suctions, but the evidence suggested he had received just three.
Recording a verdict of death by natural causes, contributed to by neglect, coroner Phillip Rogers concluded: "I am satisfied a failure of appropriate suctions of Paul's chest led to a retention of secretions.
"Therefore the failure of suctions I have considered one of the gross failings which is clearly and directly connected with Mr Ridd's death.
The inquest heard that changes had been made at Morriston Hospital following Mr Ridd's death, and a critical Ombudsman report which highlighted the failings of care in his care.
Mr Rogers added: "Mr Ridd's family have clearly taken an interest in making sure the lessons are learned from Paul's sad death.
"I believe they have brought about improvements for which they are to be commended".
Following the verdict, Mr Ridd's sister Jane and brother Jonathan issued a statement which said: "It has taken four years for the inquest to take place, so we are glad it is finally over.
"As a family we have lived and breathed the horrendous experience of our brother's death, which now has some closure.
"The inquest process seems somewhat restrictive as it is not set-up to apportion blame. However, it has confirmed the many failings identified by the public ombudsman, and Dr Turton, the independent medical advisor.
"We are pleased with the coroner's verdict, and feel that it has given us some justice."
A spokesman for Abertawe Bro Morgannwg University Health Board said: "We once more offer our sincere condolences and apologies to the family of Mr Ridd.
"We are truly sorry that whilst he was a patient on one of our wards, Mr Ridd received care which fell well below acceptable standards. Following this tragic event a thorough investigation was carried out and improvement actions identified.
"We have worked hard to address the shortcomings identified and have taken action to improve the quality of care we provide across the Health Board.
"We appreciate that these improvements in care can be of little comfort to the family of Mr Ridd. The Health Board would like to acknowledge that the concerns raised in this case have improved care for others."
Paul Ridd was admitted to the hospital on New Year's Eve 2008, for an operation on a perforated bowel, but had been moved into the hospital's intensive therapy unit (ITU).
The 53-year-old, who had undergone a tracheostomy, [corr] died three weeks later after being moved back onto Ward G due to secretions on his lungs which caused respiratory problems.
The inquest into his death at Swansea Civic Centre heard that there had been a series of failures, including a failure of communication between the ITU and Ward G for regular suctioning to be carried out to clear secretions which had built up in his throat.
In the days before his death, it had been calculated it would been expected that Mr Ridd should receive between 11 and 15 suctions, but the evidence suggested he had received just three.
Recording a verdict of death by natural causes, contributed to by neglect, coroner Phillip Rogers concluded: "I am satisfied a failure of appropriate suctions of Paul's chest led to a retention of secretions.
"Therefore the failure of suctions I have considered one of the gross failings which is clearly and directly connected with Mr Ridd's death.
The inquest heard that changes had been made at Morriston Hospital following Mr Ridd's death, and a critical Ombudsman report which highlighted the failings of care in his care.
Mr Rogers added: "Mr Ridd's family have clearly taken an interest in making sure the lessons are learned from Paul's sad death.
"I believe they have brought about improvements for which they are to be commended".
Following the verdict, Mr Ridd's sister Jane and brother Jonathan issued a statement which said: "It has taken four years for the inquest to take place, so we are glad it is finally over.
"As a family we have lived and breathed the horrendous experience of our brother's death, which now has some closure.
"The inquest process seems somewhat restrictive as it is not set-up to apportion blame. However, it has confirmed the many failings identified by the public ombudsman, and Dr Turton, the independent medical advisor.
"We are pleased with the coroner's verdict, and feel that it has given us some justice."
A spokesman for Abertawe Bro Morgannwg University Health Board said: "We once more offer our sincere condolences and apologies to the family of Mr Ridd.
"We are truly sorry that whilst he was a patient on one of our wards, Mr Ridd received care which fell well below acceptable standards. Following this tragic event a thorough investigation was carried out and improvement actions identified.
"We have worked hard to address the shortcomings identified and have taken action to improve the quality of care we provide across the Health Board.
"We appreciate that these improvements in care can be of little comfort to the family of Mr Ridd. The Health Board would like to acknowledge that the concerns raised in this case have improved care for others."
