'ONE question mark' remains over the death of a man from New Inn, near Pontypool, in hospital an inquest has heard.

Gordon Rees died on September 9, 2021 at 12.15pm. He was 65 years old.

His family since raised concerns about his care during his time at the Grange University Hospital near Cwmbran.

An inquest was opened last year and was concluded on Thursday, September 8.

Senior coroner for Gwent Caroline Saunders said that Mr Rees was a retired factory worker, he was admitted to the Grange on September 6, 2021.

The basis of the family’s concerns centre around Mr Rees’ potassium levels and whether or not they had been checked and treated properly.

On September 7 Mr Rees was seen by a cardiologist, who said he had likely suffered a heart attack.

He was also seen by a diabetic team on the same day.

He was described as “vague and difficult to converse with”.

At 8.45pm that day it was noted that he had become agitated and aggressive.

South Wales Argus:

Gordon Rees and his wife Diane 

The next day (September 8) Mr Rees’ pulmonary oedema was reportedly resolved, but his confusion remained.

That evening, he was noted as being agitated again and was refusing intervention.

On September 9 at 9.30am, Mr Rees declined a blood sugar reading, but an hour later one was taken.

At 11am that morning he was reported to be calm and able to answer questions.

However, at 11.50am, he collapsed and was found to be in cardiac arrest. He did not respond to treatment and resuscitation was stopped.

The inquest heard from Dr David Hepburn, consultant in intensive care and anaesthesia at the Aneurin Bevan University Health Board (ABUHB).

Dr Hepburn said that Mr Rees’ health was “generally not great”.

“He had a lot of complications due to diabetes and at the time of admission he had been on dialysis for 11 years.

“It doesn’t take much to upset the balance.

"His potassium was very high when he came in which can lead to heart arrythmia."

Dr Hepburn was asked what the prognosis was for Mr Rees when he arrived at hospital.

He said that the fact Mr Rees had lived for 11 years on dialysis “puts him among the luckier end of the spectrum”.

“It is testament to the people who looked after him, particularly Mrs Rees,” he said.

Dr Hepburn said that confusion such as that suffered by Mr Rees was “very common, but very non-specific” and could have been caused by many factors.

He said that, on the night of September 8, he could “fully understand” why there was an attempt made to minimise intervention overnight, due to Mr Rees’ “confusion and aggression, something I’m sure was very out of character”.

However, Dr Hepburn did agree with Ms Saunders that the decision not to check Mr Rees’ potassium levels the night before he died was “a missed opportunity”.

“If we had done a capacity check, would it have made a difference?” he asked.

“That’s the question mark for me.”

However, Ms Saunders said that there were “too many ‘woulds’ in play” for the check to have made any concrete difference.

Mr Rees’ wife, Diane, asked Dr Hepburn whether her husband should have been given sedatives.

Dr Hepburn said the answer was “probably yes”, as Mr Rees was reportedly attempted to remove the “lines” bringing medication to his neck and wrist.

Ms Saunders then noted the fact that family members took Mr Rees to hospital instead of waiting for an ambulance.

“I don’t think that Gordon’s death was contributed to by that fact,” she said.

In conclusion, Ms Saunders said that, when Mr Rees became confused and refused treatment, under the Mental Health Act, he should have been treated.

“It would have been in his best interest to have done a blood test to ascertain his potassium level,” she said.

“Whether that would’ve been possible is another matter.”

The medical cause of death was recorded as 1A – cardiac arrest.

Ms Saunders concluded that the report would record the cause of death as natural causes.

She thanked Mr Rees’ wife and daughter who were present at the inquest and said they had been “very brave” to relive the events.