Nuffield hospital missed chances to move Swansea woman – inquest

The first occasion was at 08:00 on the morning of 28 April. An ambulance was called at about16:00.

Gwynneth Exall had sought private treatment to avoid having to wait for an operation on the NHS.

The inquest in Pontypridd on Wednesday heard her blood pressure and urine levels had been low following the surgery on 27 April, before her condition deteriorated the following day.

The private hospital did not have the facilities to deal with acutely ill patients, including the rapid deterioration in Mrs Exall’s condition and cardiac arrest, according to evidence heard during the inquest.

The coroner also found there were “insufficient on-site consultants” at the hospital, with nursing staff feeling unable to escalate the situation and call an ambulance without referring to a consultant.

Ms Morgan found it was “not sufficient” for telephone consultations to take place with doctors about Mrs Exall’s condition, rather than in-person consultations.

Dr Mark Raper, an intensive care consultant at the University Hospital of Wales, told the inquest Mrs Exall should have been taken by ambulance to intensive care at another hospital hours earlier than she was.

He said if she had been transferred earlier “on the balance of probability her mortality risk would be lower”.

He told the coroner it would have been “entirely appropriate” to call an ambulance at 08:00 rather than later in the afternoon.