A coroner has criticised hospital staff for ”missed opportunities” to treat a cancer patient almost 25 years ago.
Siaron Bonds (26) from Llanrug underwent chemotherapy for lymphoma at Ysbyty Gwynedd in Bangor in September 1994. She died from complications just two days after starting treatment.
In 2008, a report by healthcare inspectors concluded a series of errors by Ysbyty Gwynedd staff had contributed to Ms Bonds’ death.
But new evidence surrounding the case and changes to the law led to a three-day inquest being held in Caernarfon.
Coroner Joanne Lees said Ms Bonds died from Acute Tumour Lysis Syndrome (ATLS) as a known side-effect to ”life saving” chemotherapy.
ATLS occurs when the rapid breakdown of cancer cells causes substances to be released into the bloodstream more quickly than the kidneys can remove them.
Ms Bonds’ condition was initally misdiagnosed as sickness and anxiety brought about by her treatment. She was not monitored regularly and a blood test was not taken until her condition deteriorated rapidly.
Ms Lees said staff missed opportunities to identify ATLS and administer treatment – but she ruled it wasn’t possible to determine if Ms Bonds would have survived if those complications were spotted sooner.
During the hearing, a consultant who treated Ms Bonds said he had asked staff to carry out an urgent blood test after discovering none had been taken when they were supposed to be.
Professor Nick Stuart said Ysbyty Gwynedd should have had a system in place to ensure tests were carried out – resulting in a ”failure of care”. He added observations by nurses weren’t done as quickly as they could have been.
Prof. Stuart agreed with Healthcare Inspectorate Wales’ finding that care had fallen ”below an acceptable standard” but he didn’t accept all of the report’s conclusions.
Siaron’s mother, Nerys Bonds, said she was admitted to Ysbyty Gwynedd on 7th September 1994 and began chemotherapy treatment the following day.
But on the morning of 9th September, Ms Bonds was very unwell. When her parents raised concerns about their daughter, Professor Stuart diagnosed anxiety.
ATLS was diagnosed at around 1.45pm that afternoon – but within two hours, Ms Bonds had passed away.
A duty doctor told the hearing Ms Bonds appeared to be doing well after treatment, but claimed her tumour may have melted with the chemotherapy. She apologised for giving Ms Bonds a dose of potassium chloride in her drip – which had not recommended for lymphoma patients.
Returning a narrative verdict, the coroner said Ms Bonds should have been given fluid via a drip in more time before her treatment started. But night staff at the hospital failed to call out a specialist when her condition worsened.
After the hearing, Ms Bonds’ sister Glenda Murray said the family had ”some partial answers to concerns which have troubled us for nearly 25 years”.
But they were ”disappointed” the coroner did not accept evidence from an expert witness – a haematology specialist who had reviewed the evidence prior to the hearing.
Mrs Murray added: ”No facts that were disclosed will ever make up for the premature and agonising loss of Siaron, a beautiful young woman and a cherished daughter and sister.”
”We have lost a sister, our children have been deprived of the opportunity to meet their aunt, our parents have spent 15 years trying to find the truth – and it is imperative that these large public organisations like the Betsi Cadwaladr health board are held accountable, and are more transparent to both patients and families.”
In a brief statement, a spokesperson for the Betsi Cadwaladr health board said: ”Our condolences are and always have been with the family.”