Family’s fight for answers leads to Prevention of Future Death report following death of Valerie Hill

Valerie Hill was a devoted mother and grandmother with a vibrant personality and a sharp sense of humour. In March 2022, she died following a significant fall at her care home and a prolonged wait for emergency care. Her family’s fight for answers culminated in a three-week inquest and the issuing of two Prevention of Future Deaths reports by the Senior Coroner for South Wales Central Area, Mr Graeme Hughes.

While the family welcomes the Coroner’s conclusions and the issuing of the Prevention of Future Deaths reports, they remain devastated by the circumstances surrounding Mrs Hill’s death.

Commenting on behalf of the family, Mr Adrian Hill, Valerie’s son, said:

“The family would like to thank all the staff involved in my mother’s care. Their professionalism and compassionate care meant a great deal to us and will always be remembered. As a family, we understand that their inability to deliver the care they wished to provide was as distressing to them as it was to us. Having worked on the front line of the NHS for 40 years, I know that my former colleagues struggle on a daily basis to provide the very best levels of care they can, often under extremely difficult circumstances. It is unfortunate that these circumstances are now all too common, a result of decades of chronic under-resourcing of the service.”

Inquest findings: Ambulance delays and missed care opportunities

The inquest heard evidence that Mrs Hill fell in her room at Ty Bargoed Care Home on 7 March 2022. An ambulance was called promptly, with staff identifying a likely fractured femur and Mrs Hill being unable to move from the floor. Despite repeated escalation calls throughout the day by both staff and family members, paramedics did not arrive until more than 14 hours later.

During this prolonged period, Mrs Hill was left in significant pain, unable to move, and received only limited fluid intake. When she was finally admitted to Royal Glamorgan Hospital, surgery was delayed until the next day. Tragically, Mrs Hill’s condition deteriorated post-operatively, and she passed away on 11 March 2022.

Expert medical evidence presented during the inquest indicated that this period of “long lie” significantly contributed to her deterioration and reduced her chances of survival.

Reflecting on the outcome, Rebecca Mather, Partner in our Clinical Negligence Department and Joint Head of our Inquest Team in Cardiff, said:

“This was an extremely upsetting and difficult three-week inquest, during which time the family acted with dignity, understanding and patience that Mrs Hill’s inquest was required to address the bigger, overarching, issues of ambulance delays in South Wales.

It should not be forgotten that at the heart of this case is a grieving family who were forced to witness their mother’s condition deteriorate during a 14-hour delay for an ambulance.

At each stage appropriate contact support and escalation was requested from the Welsh Ambulance Service NHS Trust, and it is disappointing to note that these delays are not in isolation and in fact show a clear pattern of poor care and widespread issues in South Wales. We can only hope that lessons are learnt from this inquest and that Mr Hughes’ repeated prevention of future death reports are taken with the utmost severity, as intended.”

Emily Harrison, Solicitor in the Clinical Negligence Department, who represented the family, said:

“It was a privilege to represent Valerie Hill’s family at this inquest and in relation to the wider enquiry into the ambulance and handover delays in South Wales.

The way the family dealt with the inquest was admirable. They witnessed the unimaginable trauma of their mother deteriorating as a result of failures to escalate the repeated 999 calls and fell victim to the significant handover and ambulance delays.

I sincerely hope that this enquiry results in the much-needed change across South Wales to prevent people from going through the same experience that Valerie and a family did in 2022.”

Prevention of Future Deaths reports: Summary of the Coroner’s action

The Senior Coroner for South Wales Central Area, Mr Graeme Hughes, has issued two Prevention of Future Deaths reports following a three-week inquest into the circumstances of Mrs Valerie Hill’s death in March 2022.

The lengthy and complicated inquest covered not only the factual circumstances leading to Mrs Hill’s sad death, but also the overarching issues regarding ambulance delays in South Wales – an issue of particular concern to the Coroner, who has previously issued similar reports to the First Minister of Wales, Eluned Morgan.

At the conclusion of the inquest, Mr Hughes issued Prevention of Future Deaths reports to two parties: Merthyr Tydfil County Borough Council, in relation to the management of Mrs Hill’s falls risk, and Eluned Morgan, First Minister of Wales, in response to systemic ambulance handover delays affecting health boards across the region.

The first was addressed to Merthyr Tydfil County Borough Council, raising concerns about poor or absent documentation and falls risk assessments at Ty Bargoed Care Home. Mr Hughes urged the Council to review and strengthen its procedures to protect residents more effectively.

The second was issued to Eluned Morgan as the First Minister of Wales. The report addressed and repeated concerns relating to handover targets between Welsh Ambulance Services University NHS Trust and Welsh NHS trusts resulting in significant delays in ambulance services.

In a direct and urgent appeal, Mr Hughes stated:

“The prevalence and extent of such delays has become beyond intolerable and is leading to many acutely unwell patients in the community waiting for such prolonged periods of emergency care, dying directly and indirectly as a consequence.”

The report calls for systemic reform not only within Cwm Taf Morgannwg University Health Board, relevant to Mrs Hill’s case, but across all Welsh health boards.