A CORONER said a father’s death the day after a hospital had failed to diagnose blood clots and discharged him had been “preventable".

At the end of a four-day inquest at Caernarfon, North West Wales senior coroner Dewi Pritchard Jones ruled out a conclusion of neglect but said there had been a “failure to diagnose”.

Mr Pritchard Jones said if information had been interpreted correctly at Ysbyty Gwynedd, Bangor, then 42-year-old Simon Willans should have had further tests and treatment which might have prevented the tragedy.

Mr Willans, formerly a farm worker, of Bryngwran, Anglesey, had died in January 2016 in an ambulance called after he collapsed at his parents’ home on the island.

Pathologist Dr Mark Lord said his right calf was swollen due to deep vein thrombosis and there was pulmonary embolism (a blocked blood vessel in the lungs).

The coroner concluded: “Simon Willans died of a preventable natural cause, which hadn’t been diagnosed or treated when he was in hospital on the day before his death.”

He said a report to prevent future deaths had already been issued by his assistant coroner and matters of a professional nature should be left to the relevant professional organisation. There had also been a serious incident review and expert views given.

Mr Pritchard Jones said: “It’s up to the health board to pursue those recommendations and not the role of the coroner to oversee what they are doing or not doing.”

Hospital consultant Dr Hassan Mohammed had denied at the inquest that he “failed” in his care after failing to diagnose deep vein thrombosis and pulmonary embolism.

Orthostatic hypotension – a fall in blood pressure – and anxiety had been diagnosed for his symptoms.

Dr Mohammed, a doctor for 33 years, said the General Medical Council had taken no further action against him.

Sophie Cartwright, barrister for the Willans family, told the coroner :”It’s absolutely plain from the evidence Dr Mohammed didn’t consider all the issues. He didn’t ask all the right questions.”

But Mr Pritchard Jones said: "We have no record of the consultation.” He said the doctor got the diagnosis wrong.

Miss Cartwright said a conclusion of “neglect” should be considered.

“Had Simon been given Heparin (medication to help prevent clots) he would have survived,” the lawyer maintained.

In evidence Dr Emma Hosking, medical director at Betsi Cadwaladr University Health Board’s Glan Clwyd Hospital – who chaired the serious incident review, undertaken nearly two years after the tragedy – said Mr Willans only had one set of observations including of his blood pressure and pulse while guidance suggested two.

She also told the inquest Mr Willans’s previous collapses, breathlessness and abnormal blood gas “should have prompted a rethink”.

The review panel felt Mr Willans should not have been discharged on the same day he attended the hospital.

Dr Hosking said: “Simon hasn’t been fully assessed while on the ambulatory care unit.

"The initial delay to his admission and incomplete assessment while he was there and poorly documented discharge process added up to some missed opportunities in his care.”

After the inquest, family spokesman Laurence Willans said they were not satisfied with the verdict.

He said: "We have been here four days and I feel no further forward.

“It’s very disappointing. I don’t want any money. I just wanted someone to say ‘yes it’s my fault’. I hope the board has learned lessons.

“We have lost a son and we are now struggling.”

Dr Evan Moore, executive medical director at Betsi Cadwaladr University Health Board, said: “We offer our sincere condolences to Mr Willans’s family for their loss.

"We fully accept the coroner’s findings and apologise to Mr Willans’s family for the failings in his care.

“We have changed the way referrals and processes are managed within the ambulatory care unit (ACU).

"In addition, we are carrying out continuous performance reviews within the unit to ensure the best possible care for our patients.”