19 October 2018

(WELSH VERSION BELOW) 

Before HM Coroner Mark Layton
Carmarthenshire and Pembrokeshire Coroner's Court
Wednesday 17 – Friday 19 October 2018

Heddwyn Hughes, 67, was a vulnerable adult who was in the care of Hywel Dda Health Trust at Carmarthen. The inquest into his death today concluded he was failed following a catastrophic injury whilst detained in a care home for people with learning disabilities.

Heddwyn had a lifelong learning disability, which required full time care and for Heddwyn to be detained under a Deprivation of Liberty Safeguard (DOLs). He was living in Bro Myrddin care home in Carmarthen.  

The inquest heard evidence that at around 9 am on 6 May 2015 Heddwyn – who was unable to communicate what he needed or how he felt – suddenly lost the use of all 4 of his limbs after collapsing to the floor whilst being lifted by staff.  It took around 4 hours for him to be seen by a medical professional.  It later transpired that he had broken his neck. A spinal expert told the jury that Heddwyn was likely to have become quadriplegic at the point of injury.  Heddwyn died in hospital 5 ½ months later as a result of his injury. 

The jury concluded:

• Heddwyn did not receive appropriate care and treatment from Health Board staff and was failed by an inadequate protocol;
• Health Board did not respond appropriately or with sufficient urgency following Heddwyn’s injury, or communicate adequately with his GP;
• It was not possibly to determine the cause of Heddwyn’s injury;
• The injury occurred in his bedroom just after he had walked back from the bathroom with a member of staff.

Moelwen Gwyndaf, Heddwyn’s sister on behalf of the family said: “At the centre of all this is my brother Heddwyn who was much loved and whose life required so much support.  His legacy will be that other such vulnerable adults in the care of the state and who cannot say what has happened to them will have protocols and procedures in place that will ensure their safety and care.  I would like to thank the Coroner and Jury for their thorough investigation.”

Clare Richardson of Deighton Pierce Glynn who represented the family said: “This conclusion is the result of 3 years of remarkable courage and determination by Heddwyn’s family who have overcome significant obstacles in their search for the truth”.

Deborah Coles, Director of INQUEST said: “This inquest has identified an insufficient and inappropriate response by healthcare staff to Heddwyn. These failures are all too familiar in the cases of people with learning disabilities, whose premature deaths are endemic in our health and care systems. More must be done to ensure there are sufficient and caring homes for those who need them, and society is better equipped to appropriately support people with learning disabilities.”

ENDS

NOTES

For further information and to note your interest, please contact INQUEST communications team on 020 7263 1111, Lucy McKay or here. 

INQUEST has been working with the family of Heddwyn Hughes since January 2016. The family is represented by INQUEST Lawyers Group members Clare Richardson of Deighton Pierce Glynn and Sophy Miles of Doughty Street Chambers.

Following the death of her son Oliver McGowan, Paula McGowan set up a petition to parliament, asking that they prevent avoidable deaths by making autism and learning disability training mandatory for staff in hospitals. With over 51,000 signatures, this petition will be debated in parliament on 22 October 2018. Read the petition and government response here.

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19 Hydref 2018

DATGANIAD I’R WASG

Mae'r cwest i farwolaeth Heddwyn Hughes wedi dod i'r casgliad ei fod wedi ei fethu yn dilyn anaf trychinebus tra'n cael ei gadw mewn gofal am anableddau dysgu

O flaen Crwner EM Mark Layton
Llys Crwner Sir Gaerfyrddin a Sir Benfro
Mercher 17 - Gwener 19 Hydref 2018

Roedd Heddwyn Hughes, 67 oed, yn oedolyn bregus a oedd yng ngofal Ymddiriedolaeth Iechyd Hywel Dda yng Nghaerfyrddin. Daeth y cwest i’w farwolaeth i'r casgliad ei fod wedi ei fethu yn dilyn anaf trychinebus tra'n cael ei gadw mewn cartref gofal i bobl ag anableddau dysgu.

Roedd gan Heddwyn anabledd dysgu gydol oes, a oedd yn gofyn am ofal llawn amser ac i Heddwyn gael ei gadw dan reolau I ddiogelu pobl y’u hamddifadwyd o rhyddid. Roedd yn byw yng nghartref gofal 79 Bro Myrddin yng Nghaerfyrddin.

Clywodd y cwest dystiolaeth bod Heddwyn - a oedd yn methu cyfathrebu ei anghenion - ar y 6ed o Fai 2015, wedi colli'r defnydd o bob un o'i freichiau a’i goesau. Cymerodd oddeutu 4 awr iddo gael ei weld gan weithiwr meddygol proffesiynol. Yn ddiweddarach daeth yn amlwg ei fod wedi torri ei wddf. Dywedodd arbenigwr asgwrn cefn wrth y rheithgor fod Heddwyn yn debygol o fod wedi colli defnydd o’i freichiau a’i goesau adeg yr anaf. Bu farw Heddwyn yn yr ysbyty 5 ½ mis yn ddiweddarach o ganlyniad i'w anaf.

Daeth y rheithgor i’r casgliad:

• Ni dderbyniodd Heddwyn ofal a thriniaeth briodol gan staff y Bwrdd Iechyd ac fe'i fethwyd gan brotocol annigonol;
• Ni ymatebodd y Bwrdd Iechyd yn briodol neu gyda digon o frys yn dilyn anaf Mr Hughes, na chyfathrebu'n ddigonol â Meddyg Teulu Heddwyn;
• Nid oedd hi'n bosibl pennu achos anaf Heddwyn;
• Digwyddodd yr anaf yn ei ystafell wely ar ôl iddo gerdded yn ôl o'r ystafell ymolchi gydag aelod o staff.

Meddai Moelwen Gwyndaf, chwaer Heddwyn ar ran y teulu: "Yng nghanol hyn oll mae fy mrawd Heddwyn, a garwyd yn fawr, ac a oedd angen cymaint o gefnogaeth. Ei etifeddiaeth yw y bydd yna weithdrefnau ar waith er mwyn sicrhau diogelwch a gofal I oedolion bregus eraill sydd yng ngofal y wladwriaeth, ac sydd yn anabl I ddweud beth sydd wedi digwydd iddynt. Hoffwn ddiolch i'r Crwner a'r Rheithgor am eu hymchwiliad trylwyr. "

Dywedodd Clare Richardson, o Deighton Pierce Glynn, a oedd yn cynrychiolu’r teulu: "Mae'r casgliad hwn yn ganlyniad i 3 blynedd o ddewrder rhyfeddol a phenderfyniad gan deulu Heddwyn sydd wedi goresgyn rhwystrau sylweddol wrth chwilio am y gwir".

Dywedodd Deborah Coles, Cyfarwyddwr INQUEST: "Mae'r cwest hwn wedi nodi ymateb annigonol ac amhriodol gan staff gofal iechyd i Heddwyn. Mae'r methiannau hyn yn rhy gyfarwydd yn achos pobl ag anableddau dysgu, y mae eu marwolaethau cynamserol yn endemig yn ein systemau iechyd a gofal. Rhaid gwneud mwy i sicrhau bod cartrefi digonol a gofalgar ar gyfer y rhai sydd eu hangen, a bod cymdeithas yn meddu ar yr offer gorau i gefnogi pobl ag anableddau dysgu yn briodol. "

ENDS

NOTES

Am ragor o wybodaeth ac i nodi'ch diddordeb, cysylltwch â thîm cyfathrebu INQUEST ar 020 7263 1111, Lucy McKay ar [email protected] (English speaking only).

Mae INQUEST wedi bod yn gweithio gyda theulu Heddwyn Hughes ers mis Ionawr 2016. Cynrychiolir y teulu gan aelodau Grwp Cyfreithwyr INQUEST Clare Richardson o Deighton Pierce Glynn a Sophy Miles o Siambrau Stryd Doughty.

Yn dilyn marwolaeth ei mab Oliver McGowan, sefydlodd Paula McGowan ddeiseb i'r senedd, gan ofyn eu bod yn atal marwolaethau y gellir eu hosgoi trwy wneud awtistiaeth a hyfforddiant anabledd dysgu yn orfodol ar gyfer staff mewn ysbytai. Gyda dros 51,000 o lofnodion, trafodir y ddeiseb hon yn y senedd ar 22 Hydref 2018. Darllenwch yr ddeiseb a'r ymateb i'r llywodraeth yma.

INQUEST yw'r unig elusen sy'n darparu arbenigedd ar farwolaethau yng ngofal y wladwriaeth a'u hymchwiliad i bobl, cyfreithwyr, asiantaethau cynghori a chymorth, y cyfryngau a seneddwyr sydd wedi dioddef profedigaeth. Mae ein gwaith achos arbenigol yn cynnwys marwolaeth yng ngofal yr heddlu a chadwraeth y carchar, cadw mewnfudo, lleoliadau iechyd meddwl a marwolaethau sy'n ymwneud â methiannau aml-asiantaeth neu lle mae materion ehangach o atebolrwydd y wladwriaeth a chorfforaethol dan sylw, megis marwolaethau a materion ehangach o gwmpas Hillsborough a Thwr Grenfell. Mae ein gwaith polisi, seneddol, ymgyrchu a chyfryngau yn seiliedig ar brofiad o ddydd i ddydd o weithio gyda phobl sydd mewn profedigaeth. Cyfeiriwch at INQUEST y sefydliad ym mhob prif lythyr er mwyn ei wahaniaethu o'r gwrandawiad cyfreithiol.