NEGLECT played a part in a Cwmbran woman's death at the Royal Gwent Hospital, a coroner has ruled.

The coroner described "numerous" failures in the care provided to Nicola Samuel, of Cwmbran, while she was in hospital.

Ms Samuel, 33, had fallen ill in October 2019 with diarrhoea and vomiting.

After check-ups with GPs, she was eventually admitted to hospital on November 8 after a doctor found signs of dehydration.

Ms Samuel, who had cerebral palsy and was confined to a wheelchair, underwent an operation for a bowel obstruction on November 14, but died three days later following a seizure after time spent in intensive care.


Newport Coroner's Court heard how, despite warning signs Ms Samuel's condition was worsening, proper checks were not carried out in hospital.

Deputy ward manager, Nicola Jones, explained she "couldn't understand" why more regular checks were not being done as Ms Samuel scored threes and fives on the National Early Warning score.

A score of three should prompt hourly observations by staff and a doctor should be alerted to check on a patient within 30 minutes.

This was not done on November 10, and there was no evidence it was done on November 11, or November 13.

During this time, an x-ray had been carried out on Ms Samuel's abdomen, which Dr Gethin Williams, the surgeon who eventually operated on Ms Samuel, described as "abnormal".

"You would hope that most seeing this x-ray would know it is abnormal," he said. "It should set alarm bells ringing.

"You would have expected to come and see the patient. There is no evidence that the surgeon registrar did that. It is quite disappointing."

He added: "Earlier intervention could possibly have made a difference.

"The chances of survival earlier would be much higher."

Speaking as she delivered her conclusion, Caroline Saunders, chief coroner for Gwent said: "Nicola was born with cerebral palsy which rendered her dependent on a wheelchair, but aside from asthma she did not have significant health problems.

"I find that a surgical review should have taken place sooner, and a CT scan should have been carried out which would have discovered the obstruction.

"I am not convinced that would have been followed immediately by surgery, but she would have been observed closely.

"As it was she was observed on the medical ward where, despite concerns, she was not observed to anything close to an acceptable standard.

"Had she been in the care of the surgical team, as she should have been, it is likely she would have undergone surgery at this point if she had not already.

"The bowel had not perforated at this stage and therefore the outcome would have been better."

Delivering a conclusion of natural causes contributed to by neglect, Ms Saunders added: "The failures in the care offered to Nicola are numerous.

"There was failure to ensure a surgical assessment at any time before November 14.

"There was failure to undertake a CT scan before November 14.

"There was a failure to undertake checks in line with national guidelines.

"A gross failure is more than a simple error and I consider these to be more than simple errors.

"It should have been obvious that Nicola needed the care.

"If she had been assessed by the surgeons earlier she would have gone to surgery earlier than November 14.

"I do not consider that Nicola would have died when she did if that was the case, therefore these failures have more than minimally lead to Nicola's death."

The Aneurin Bevan University Health Board, which runs the Royal Gwent Hospital, was contacted for comment.