Anglesey man died the day after a hospital had failed to treat symptoms of blood clots

Simon Willans, formerly a farm worker, of Bryngwran in Anglesey, had died in an ambulance called after he collapsed at his parents’ home.

At a Caernarfon inquest, pathologist Dr Mark Lord said the right calf was swollen due to deep vein thrombosis and there was a pulmonary embolism.

“If recognised before death, anticoagulant treatment is effective,” Dr Lord remarked.

The pathologist had raised his concerns with the coroner after conducting the post-mortem examination. A Home Office pathologist also carried out an examination and police launched a probe. But the Crown Prosecution Service decided against further action.

Concerns about Mr Willans’s care at Gwynedd Hospital, Bangor, in January 2016, had caused assistant coroner Nicola Jones to issue a report to prevent future deaths, even before the full inquest. It said he had been discharged, seemingly by a nurse practitioner who had no involvement in his care, with orthostatic hypotension – a drop in blood pressure - and anxiety diagnosed.

When a three-day inquest began yesterday, GP Dr Huw Lloyd Evans said he had seen Mr Willans and the patient’s mother Lynne had also been present at the surgery. Dr Lloyd Evans said: "The fact she was there made me think there was something unusual going on. They told me about the shortness of breath, passing out and dizziness.”

The doctor said: "I thought he needed admission that day. I phoned the hospital to speak to the duty officer to try and arrange an admission.

“They let me know they were very busy and asked if referral would be more appropriate.”

The hospital had been “chock-a-block”.

Dr Lloyd Evans said: "In the past I have pressed harder for an admission that day. But it’s ended up in an argument.”

The GP also said he had seen many patients with shortness of breath. “I can’t give them all Heparin (an anticoagulant) in case they have a clot,” he told North West Wales senior coroner Dewi Pritchard Jones.

The GP said: "I would have preferred him to be seen that day but I compromised on him being seen the next morning.”

Laurence Willans said a hospital nurse had told him his breathless son was “very stressed.”

He told the coroner: "It was as if they just thought he was stressed out and that was what was causing it. That was the impression I got.”

He had told his son: "At least you know you have been in the hospital and checked out.”

Mr Willans died on January 27, 2016, at Ty Croes in Anglesey. Hospital doctors are being called to give evidence and Mr Pritchard Jones said the hearing would go into what had been learned from the tragedy.

Later yesterday Ffion Simcox, an advanced nurse practitioner at the hospital, said: "When he first arrived on the unit he did appear a little clammy and a bit breathless. However, when I was assessing him he wasn’t breathless.”

But Mrs Simcox said she spotted the right leg was swollen and she arranged for more blood tests and a scan. She had also questioned Mr Willans about risk factors for clots.

A Doppler test found no major DVT.

“I thought a leg 3.5cms bigger, justified a scan,” she said. She had presented her findings to a doctor yet to give evidence. Mrs Simcox said she felt she had gone “as far as I could” to establish why the leg was swollen.

She suspected DVT and a potentially life-threatening pulmonary embolism - a blocked blood vessel in the lungs - but didn’t have the authority herself to order further tests.