A WOMAN died at a hospital in Bangor after medical notes referring her for further tests were lost, an inquest heard.

Jennifer Lydia Campbell died aged 73 at Ysbyty Gwynedd on February 24, 2022.

Following the inquest into her death, which concluded on October 24, a Prevention of Future Deaths (PFD) report has been submitted to Betsi Cadwaladr University Health Board (BCUHB).

Kate Robertson, senior coroner for North West Wales, recorded a narrative conclusion, and a medical cause of death of pneumonia and sepsis, contributed to by obstructing gallstones.

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The inquest had heard that Ms Campbell had an ultrasound scan of her abdomen on October 25, 2021, which showed gallstones; her GP then referred her for a gastroenterology three days later.

Following review, a paper referral was made by a gastroenterologist for endoscopy, but for reasons unknown, this was not received by the endoscopy department.

Ms Campbell was then admitted to Ysbyty Gwynedd on February 23, 2022 having been vomiting for two days, and was treated for severe infection due to obstructing gallstones.

But her condition deteriorated in hospital, and she died the day after her admission.

In her PFD report, Ms Robertson wrote: “It appears that, only during the course of inquest proceedings, did the issue relating to the lost referral become known to the health board.

“Even once it became known to them in 2022, there was still no investigation undertaken. It is not understood at all which incidents that occur are to be investigated.

“I have issued a number of PFD reports relating to investigations and governance, and yet these concerns continue. I am not in any way satisfied that improvements have occurred.

“Given that no investigation was conducted to understand how the issue may have occurred, there has been no learning, change or improvement to ensure it is not repeated.

“I have been provided with no assurances in this regard.

“Such referrals remain paper-based and there is no indication as yet when these will be fully electronic.

“I am aware that this national strategy is ongoing, but the time it is taking is putting patients’ lives at risk.”

BCUHB is duty-bound to respond to the report by December 19, containing details of action taken or proposed to be taken, and setting out the timetable for action.

Otherwise, the health board must explain why no action is proposed.