Nurses ‘not at fault’ over Oswestry man’s death, coroner rules

By Sue Austin | St Martins | News | Published:

Hospital staff did not fail in their duty of care towards a man who left an emergency department without seeing a doctor and died hours later, a coroner has ruled.

Guy Evans

Guy Evans, of Greenfields, St Martins, near Oswestry, hit his head during a pub crawl on October 8.

The 25 year old was taken to Wrexham Maelor Hospital at about 8pm but left before 9pm, before he could be seen by a doctor.

He fell and hit his head again in the early hours of the following morning and died at Royal Shrewsbury Hospital. An inquest into his death at Shirehall, Shrewsbury, yesterday heard from nursing staff who said Mr Evans was assessed and was waiting for a doctor when he decided to leave.

Staff nurse Ceri Vernon said she had carried out observations and Mr Evans was triaged to be seen by a doctor within an hour.

Matron Jayne Gregory told the inquest: “The category was a recommendation he would be seen in an hour by a doctor but Guy did not even wait for that hour. I am happy Guy was triaged correctly. It is very difficult when patients decide not to wait. If he had shared he was going to leave, staff would have asked him not to. If he still made that decision to leave then it is out of our hands. Somebody with capacity is free to leave.

“In triage, the conversations will be along the lines of ‘take a seat and you will be seen by a doctor’.”

At an early hearing, John Ellery, senior coroner for Shropshire, Telford and Wrekin, was told that Mr Evans, known as ‘Sharkie’ due to his prowess on the pool table, left Wrexham Maelor Hospital and went into Oswestry where he continued drinking.

At about 2am on October 9 he went to USA Fried Chicken in Willow Street but once again fell and hit his head. An ambulance was called and police also attended. Mr Evans was found unconscious on the ground. He was given CPR before being taken to RSH where he later died.


Recording a verdict of accidental death, Mr Ellery said it was not possible to say which fall contributed to or caused Mr Evans’ death.

He said: “If I have to resolve whether nursing staff told Guy he should stay to be seen, I don’t believe she did but I believe it would be reasonable Guy would have known he was to be seen by a doctor because that was the point of going to A&E.

“I am also conscious that Guy’s friend said they had been drinking and I can’t accept his evidence that effectively Guy was told he was free to go.

“It would have been against procedure and protocol and I have no reason to doubt Nurse Vernon did not follow normal procedure and protocol.


“All in all I can’t say there was any failure at Wrexham Maelor which caused or contributed to his death.”

The news of Guy’s death devastated the community as he was well known by many for being a regular in The Keys in St Martins and pubs in Oswestry, where he’d often jump on the karaoke, as well as joining in on hen and stag parties.

His mother Helen Evans said her son, who had dwarfism, lived his life to the fullest – despite his condition.

John Smout, a good friend of Guy’s, said St Martins had lost one of its “biggest characters”. Guy left his parents Clifford and Helen, as well as brothers, Wayne and Lee, and sisters Heidi, Emma and Jessica.

Sue Austin

By Sue Austin
Chief Reporter

Chief reporter of the Oswestry/Mid Wales office. Keen to hear your news.

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