A CONSULTANT was so concerned that a delay in fixing a hospital appointment may have contributed to the death of one of his patients that he referred the matter to the coroner.

The Betsi Cadwaladr University Health Board held a serious incident review (SIR) following the unexpected death of 86-year-old Mrs Iris Malcolm but after considering all the evidence the consultant, Dr Stephen Wong, said his fears had been allayed.

He told an inquest in Ruthin he had been shocked by her death, adding: “We are using this unfortunate case as a learning lesson to educate colleagues.”

And Mrs Malcolm’s son and daughter-in-law Clifford and Carol Malcolm, said they hoped the steps taken since would help prevent any future deaths.

Mrs Malcolm, a retired civil servant, had various health problems when she moved from Kent to live with them in Berwyn Crescent, Kinmel Bay, in 2015. She had a heart condition and osteoporosis and had suffered a stroke, and in September 2016 was admitted to Glan Clwyd Hospital with a swollen goiter, or thyroid gland, for which she had been treated in Kent.

Dr Wong, consultant in diabetes and endocrinology, said her condition was stable and a note was made for her to return to his clinic in March, 2017.

When no appointment was received Mrs Carol Malcolm rang the hospital several times to ask what was happening.

In April and May her mother-in-law went to hospital for other matters for which she was treated, and she was also seen twice by her GP but there was nothing to indicate any problems with her goiter.

On November 19 – still without having had a follow-up appointment with Dr Wong – she was admitted to hospital because of breathing difficulty caused by the goiter.

The consultant told the inquest: “When I saw her on the 20th I was completely shocked. She was in a terrible state.”

The condition was deemed to be inoperable partly due to Mrs Malcolm being so frail, and she died the following day.

Asked by Joanne Lees, assistant coroner for North Wales East and Central, how long it would have taken for the goiter to grow so large, Dr Wong said that in 20 years he had never known one grow so quickly.

“It appears to have occurred within 24 hours. It was very unusual,” he said.

He said he immediately wondered whether the failure to fix an appointment within six months of having seen her in September, 2016, had contributed to her death.

“That is why I referred it to the coroner.” He said.

But he told Mrs Lees that he was now satisfied that no opportunities had been missed on her other visits to hospital or by her GP, and that view had been confirmed by an independent consultant from another hospital board.

Dr Wong said that since the SIR appointment procedures had been tightened and steps taken to clear the backlog. Clinicians in other departments had also been alerted to the risks posed by enlarged goiters.

Mrs Malcolm’s cause of death was given as broncho-pneumonia and respiratory failure, with the goiter as a contributory factor.

Recording a conclusion of natural causes, the assistant coroner said she acknowledged the family’s concerns, but added: “I cannot find any evidence that if Mrs Malcolm had been seen by Dr Wong in March or April the outcome would have been any different.”

She also said she saw no need to issue a Regulation 28 report to prevent future deaths.

“I am satisfied my concerns, which I shared with you, have been addressed,” she added.