Failings at Powys hospital as man died with gangrene

Powys County Times

11-07-2025

A coroner has said there were "missed opportunities" in the treatment of a a Powys man who developed gangrene and was seen at four different hospitals before dying at a fifth.
Edward John Funnell lived in Llandrindod Wells, died at Ystradgynlais Community Hospital on April 29, 2023, aged 93, and with an ischemic left foot, vascular disease and congestive cardiac failure.
Mr Funnell, a Londoner who moved to Llandrindod in later life following the death of his wife, was described as a master carpenter and an avid Crystal Palace fan.
At an inquest conclusion on Thursday, July 10, coroner Andrew Morse said there were failings, especially during a stay in Llanidloes War Memorial Hospital, but they did not constitute neglect.
He is to send a report to Powys Teaching Health Board detailing a 'number of areas of concern'.
'Finding neglect means finding gross failure that caused his death,' Mr Morse said at the hearing at Pontypridd Coroner's Court.
'In this case, it is unsafe. I cannot safely conclude that the failings constituted gross failure or neglect.'
Mr Funnell's three-day inquest in June heard that problems arose after he was admitted to Hereford County Hospital in December 2022, for an operation on his hip.
His day-long procedure turned into a prolonged stay after he developed a pressure sore ulcer on his left heel, then deep vein thrombosis (DVT).
He was transferred to Llanidloes Hospital on January 11, 2023, with the handover described by the coroner as 'poor'.
'There was only partial information handed over,' said Mr Morse.
'GP Dr Rainsford said no definitive answer was given as to the site of the clot. There were concerns raised as to the difficulties experienced in Llanidloes in contacting Hereford.
'In Llanidloes it was clear there was a delay in photographing the heel area on admission. It was known he had a pressure sore.
'There are clear failures in identifying which area and there were scant details in the paperwork. Although not causative, these are matters of concern."
He said staff not applying the correct wound dressing delayed the healing process.
'There was no follow up to see a podiatrist, as advised by a tissue viability specialist, before it became ischemic.
'It is difficult to say if it would have made a difference, but it would have provided chance to see a specialist. It was not fully escalated to doctors until he was admitted to Bronglais by emergency ambulance.
'There are worrying gaps in the knowledge of nursing staff in treating pressure sores and vascular issues in general. There were missed opportunities.'
Mr Funnell was admitted to Bronglais Hospital in Aberystwyth on February 2, with a doctor indicating a need for further investigation. He was admitted again on February 19, by which time his lower leg was black and his limb not salvageable.
He was transferred to Morriston Hospital in Swansea, where the only viable option was amputation.
Mr Morse said Mr Funnell understandably opted against a 'significant surgery'. He received palliative care in Ystradgynlais until his death.
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Mr Morse said he would file a report for prevention of future deaths.
'Clearly, with the way Edward's ischemia developed rapidly, there is a risk which engages my duty to complete a report," he said.
"There were also issues with record keeping and a failure to escalate matters.
'There are a number of areas of concern, which I'll distil into a report to be sent to Powys Teaching Health Board.'