A PENSIONER died almost six weeks after she had been admitted to Ysbyty Gwynedd and only days after she had received a correct diagnosis, an inquest heard.

Nesta Jones died at the Bangor based hospital on May 8, 2017 at the age of 77.

Following an inquest into her death, which concluded on February 28, Kate Robertson, senior coroner for North West Wales, recorded a narrative conclusion.

Mrs Robertson has since issued a Prevention of Future Deaths report, which has been sent to Betsi Cadwaladr University Health Board (BCUHB).


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Ms Jones’ cause of death was noted as bronchopneumonia, contributed to by septic arthritis and immunosuppression and rheumatoid arthritis.

The inquest heard that Ms Jones had been in hospital for 39 days before she died at Ysbyty Gwynedd.

She was admitted to hospital by a general practitioner with suspected septic arthritis of a prosthetic left knee, but did not undergo aspiration until May 5.

This was despite aspiration being indicated by hospital guidelines; by the time aspiration was undertaken, her condition was “irrecoverable”.

While Ms Jones was referred to a number of orthopaedic doctors with suspected septic arthritis, this diagnosis was not considered.

Ms Jones’ family wrote a letter, marked “urgent” to the health board’s chief executive on May 3, requesting consideration of her care as “a matter of life or death” urgency.

This received no response, with Mrs Robertson writing in her report that “the health board did not have adequate and appropriate systems and processes for dealing with such complaints and concerns”.

Following Ms Jones’ death, the health board did not undertake a full investigation into the circumstances surrounding it besides a “desktop report”, which was described as being of “questionable” quality.

As such, Mrs Robertson wrote, “there were no formal considerations as to immediate actions or learning required to reduce harm and the risk of death”.

The inquest also heard that there were concerns that junior doctors may not be "encouraged to challenge or discuss their findings" to their more senior colleagues, thus presenting a risk of missing diagnoses.

It was also told that a new governance process is being considered by the health board, and is likely to be in force by next month.

But, Mrs Robertson said: “I have made previous reports on this precise point, and yet the new and improved process is still not in place.”

BCUHB must respond to the report within 56 days of its publication date.

What the Health Board has said:

Dr Nick Lyons, Executive Medical Director at Betsi Cadwaladr University Health Board, said: “On behalf of the Health Board we are profoundly sorry and offer our deepest sympathies to Nesta’s family for their loss. 

“The care Nesta received fell below the standards we and her family would expect, and we apologise for this. 

“The health board has taken a number of actions since Nesta’s tragic death in 2017 and continue to learn, improve our services and support the needs of our patients and families. 

“Two Consultant Orthopaedic Consultant Surgeons have been appointed at Ysbyty Gwynedd with a special interest in revision arthroplasty and infection. 

“The Septic arthritic guidelines are much more accessible via internal channels as well as circulating them with our new starters.  This is also supported by an education and awareness programme for orthopaedic clinicians, which is offered during their induction period and Clinical Governance days. 

“To enable patients and their families to have more involvement in their health care treatment decisions there is now also a Call 4 Concern service at Ysbyty Gwynedd (since 2022). Patients’ loved ones know them best and can sometimes be the first to recognise subtle changes in their condition – Call 4 Concern provides them with an opportunity to independently raise concerns with highly skilled clinicians if they believe the patient’s clinical condition is deteriorating. 

“The health board takes the coroner’s findings very seriously and we will continue to ensure we learn and address the concerns raised in her conclusion. We will fully respond to her concerns in due course.”