Overview

• Patricia Morgan concluded that multiple delays on February 8 more than minimally contributed to Bethan James’s sepsis-related cardiac arrest.
• Ambulance crew did not issue a pre-alert to University Hospital Wales, resulting in her placement in the lower-acuity majors area instead of direct admission to resuscitation.
• Dr Chris Danbury testified that aggressive intervention upon arrival could have prevented her cardiac arrest and improved survival odds.
• James, diagnosed with Crohn’s disease in 2019, experienced weeks of dismissed gastrointestinal and respiratory symptoms before her final collapse.
• The health board has been given seven days to explain why life-saving pre-alert protocols used in England were not routine in Cardiff.