A "number of shortcomings" have been identified in the care given to a man who died in hospital.
Robert Huw Summerhill died in the early hours of Christmas morning in 2019 after being admitted to the Royal Glamorgan Hospital with back pain and vomiting on December 23. Mr Summerhill, from Porth, was just 42 years old at the time of his death and was working for Royal Mail as a postman.
An inquest held at Pontypridd Coroners' Court on Thursday heard that Mr Summerhill was diagnosed with severe acute pancreatitis and a plan was put in place for his treatment including monitoring his fluid input and output – a vital aspect of treatment for pancreatitis.
Coroner David Regan described how there were at least three shortcomings identified with Mr Summerhill's care during his short period in hospital.
Evidence provided by doctors told how Mr Summerhill - the brother of Cardiff Blues winger Aled Summerhill - was on and off the acute care ward for several scans through the day on Christmas Eve, which meant his fluid output was not recorded by nursing staff.
At the hearing Debra Matthews, head of nursing for the acute services at the Royal Glamorgan Hospital, described how an investigation carried out by the health board into the care Mr Summerhill received has since discovered that because of his preference not to be catheterised Mr Summerhill should have been escorted off the ward to attend multiple scans in order to record any passing of urine. However this did not happen and Mr Summerhill left the ward to attend a CT scan, an MRI scan, and an ultrasound scan on his own. The hearing heard how Mr Summerhill passed urine three times within that period but the output was only recorded once.
Describing the importance of monitoring fluid input and output Dr Nader Naguib, on-call consultant at the time, said: "The function of the pancreas is mainly digestion. The treatment is always to give as much fluid as is lost. The way we can know how much they need is to monitor how much fluid they lose."
Mr Summerhill was admitted to the A&E department at the hospital at 11.30pm on December 23 after suffering with worsening back pain for the preceding two days. Several months earlier he was treated for osteomyelitis – an infection in his collar bone which was the suspected cause of his back pain.
Blood tests ruled out this prognosis but found inflammation of the pancreas and a diagnosis of acute severe pancreatitis was given. A post-mortem examinationdiscovered Mr Summerhill was suffering from hemorrhagic pancreatitis.
Dr Naguib said that Mr Summerhill's condition appeared to improve throughout the day on Christmas Eve and he was feeling better in himself, talking to his visiting family and using his phone.
He explained that Mr Summerhill's condition was measured on a chart of one to 10 and recorded a score of two that morning, which is the lower end of the risk scale. However observations were taken by nursing staff at 4.20pm who measured a score of five. Before this it had already been decided Mr Summerhill should be moved to the surgical ward, where there were more experienced nurses, to monitor his situation.
After listening to evidence from Dr Naguib, Mr Regan said: "That score should have resulted in a doctor to be called and that doctor should have been a surgical team. That did not occur and members of the surgical team were unaware."
Mr Regan said that this was the second of the three shortcomings identified with the first being the inability to monitor Mr Summerhill's urine.
The third shortcoming Mr Regan identified was the lack of an escalation plan in the instance that Mr Summerhill was to be transferred to intensive care. Dr Naguib said a registrar on shift had discussed this with a member of the ICU team who were aware of Mr Summerhill's situation but no formal plan was drawn up.
Mr Summerhill was transferred to the surgical ward from the acute ward at 9.15pm on Christmas Eve and it was apparent he had become seriously ill. An hour later he suffered a seizure and respiratory care was given for the next hour. By 11.30pm it was clear Mr Summerhill was too ill to survive and he died at 4.20am on December 25.
A pathology report discovered Mr Summerhill was suffering with hemorrhagic severe acute pancreatitis as well as liver cirrhosis, likely caused by longer-term alcohol consumption.
Discussing these findings Dr Naguib said severe acute pancreatitis had a mortality rate of 25% but with two organs failing in this way it was likely that mortality rate was around 50%. Mr Regan recorded a conclusion of natural causes.
Following his death Mrs Matthews said a review of Mr Summerhill's care was carried out and a new pathway was designed for the guidance of care for patients with pancreatitis. She said the full implementation of the pathway was intended to be complete by the end of last year but it had been delayed by the pandemic. However she said more than 50% of the nursing staff on the wards concerned have received the correct training.
In the wake of his brother's death rugby player Aled posted an online tribute saying: "My brother will always be in my heart."
