On 3 November 2014 commenced an investigation into the death of Vera Hilda Williams aged 77 The investigation concluded at the end of the inquest on September 2015_ The conclusion of the inquest was Medical Cause of death: 1a. Massive Gastrointestinal Tract Haemorrhage due to 1b. Oesophageal-Aortic Fistula due to 1c. Oesophageal Rupture. Conclusion Death was due to an accident:

Mrs Williams attended the Emergency Department of Glan Clwyd Hospital on 10 October 2014 complaining of pain after eating toast She was given pain killers and observed to be swallowing: Mrs Williams was examined Upon a review the pain had been resolved and she was sent home. The Emergency Department doctor took the view that there had been an obstruction which had resolved itself. Mrs Williams returned to the Emergency Department on 23 October 2014 complaining of pain in the left side of her face and back of her neck_ Usual Observations and bloods taken. Her chest was examined but not X rayed. Mrs Williams was discharged home at 02.20 hours with oral antibiotics and painkillers_ She was suspected of having a mild upper respiratory tract or urinary infection: Mrs Williams attended the Emergency Department at 19.09 after calling an ambulance at 17.46 on 24 October 2015. She had coughed and vomited a blood clot She was generally unwell: At 16.00 hours on 25 October 2015 after other investigations including Chest Xray, Bloods, General observations and physical examination a CT scan revealed that Mrs Williams had a ruptured aorta It is probable that this was caused by swallowing the toast which was complained of on her first visit to the emergency Department on 10 October 2104.- Surgical intervention was not appropriate for Mrs Williams she died on 28 October 2015 at Glan Clwyd Hospital_ The presentation for Williams was different on the three separate occasions that she attended the Emergency Department The Doctors on call had to rely upon Mrs Williams to tell them that she had been admitted previously and what had occurred on those previous visits to the Emergency Department In this case it was only the CT Scan which showed the Oesophageal Rupture. The presentation of Mrs Williams on the 10th and 24 th October was not such that a CT Scan could reasonably be expected to be carried out on the examination and presentation of Mrs Williams on those occasions_ and Mrs

In my opinion action should be taken to prevent future deaths and believe your organisation has the power to take such action: