Bethan James should still be alive today, so why has her family had to fight for five years to get answers?

Wales Online

2 days ago

Bethan James should still be alive today, so why has her family had to fight for five years to get answers?
The 21-year-old's devastated family have said it has been losing her all over again after an inquest found her death could have been prevented
Bethan James died following an avoidable cardiac arrest
(Image: Steve James )
Bethan James should still be alive today. Her parents Steve and Jane James have known this ever since medics at the University Hospital of Wales in Cardiff pronounced her dead on February 8, 2020. But it has taken more than five painful years of 'fighting tooth and nail' for a coroner to finally validate it as true.
In June an inquest found that talented young journalist Bethan died due to a combination of pneumonia and sepsis, which was complicated by the immune suppressing effects of her previously diagnosed Crohn's disease.
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It saw the 21-year-old from St Mellons in Cardiff suffer a cardiac arrest which doctors could have and should have prevented, it was heard.
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In the week before her death doctors failed to recognise the seriousness of her condition and Bethan was never admitted into hospital.
She was dismissed and told that she would likely be 'symptom free' in a matter of weeks, before she struggled to walk a short distance back to her family's car.
Then on Saturday, February 8, 2020, medics failed to recognise or act on Bethan's symptoms of sepsis until it was too late.
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Over the next five years Steve and Jane were denied an inquest into Bethan's death on three occasions, despite them being adamant that a number of mistakes had been made.
It was only when lawyers acting on behalf of the family threatened a judicial review that an inquest was agreed to go ahead, taking place earlier this month.
'If there had been an inquest straight away things would have been a lot different,' said Steve, a former cricket star and sports writer for The Times. 'I dread to think how many people have died in the same sort of way in the last five years.'
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Steve and Jane outside Pontypridd coroner's court
(Image: John Myers )
Coroner Patricia Morgan, who oversaw the inquest, said that Bethan likely 'would not have died' if medics at Cardiff and Vale University Health Board (CVUHB) and the Welsh Ambulance Service Trust (WAST) acted appropriately sooner.
Steve and Jane have received an apology from WAST, but are yet to receive one from CVUHB.
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Ms Morgan asked the health board to set out why certain routine life-saving sepsis are routine in English hospitals, but are seemingly not implemented at the University Hospital of Wales in Cardiff, where Bethan died.
The health board told WalesOnline it has met its deadline for sending that information, and Ms Morgan will now consider the evidence to decide if a regulation 28 to prevent future deaths should come into effect.
Although the outcome of the inquest confirmed the family's intuition all along, Steve and Jane said the validation offers them little closure.
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Jane, a physiotherapist for Sport Wales, said: 'The whole thing is torture, but to think it has been five years that we have been pushing for this, and what it has taken out of us emotionally. It is constantly in your head and you are constantly waiting for the next email.
'All of these things should have happened in that first year and we should have had all the answers within the first year and we have still been learning new things in the inquest.'
Bethan with her parents Steve and Jane James with her younger brother Rhys
(Image: Steve James )
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Getting emotional and turning to her husband, she said: 'I don't know about you, but the grief feels worse at the moment.'
Steve replied: 'It feels like she has died again. It is horrendous.'
He added: 'We are obviously happy with the conclusion because it is what we said and thought all along.
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'But it doesn't give us closure, it actually makes it worse because it validates the fact that she should be here and it doesn't make anything better.
"But from our point of view, we said all along that we had to fight for Bethan, we had to fight for justice.
'The coroner saying that she shouldn't have died is pleasing for us in terms of all the work we've had to do to get to that point.'
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They said part of that fight had been getting their hands on Bethan's medical notes, which they described as being a long and laborious process.
Once they received the notes Jane said she was taken aback by 'how poorly' the notes were written, including notes not being signed and others written in retrospect after Bethan's death.
Steve and James want Martha's Law to be rolled out to all hospitals in Wales
(Image: Steve James )
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She said: 'My heart goes out to any families that have to go through anything like this process to get answers from the NHS and find out what happened to their relative because having experienced what we have gone through, with those barriers put up when you are at the lowest point in your life; you look for answers and you are constantly pushed back.'
Steve added: 'We've been lucky Jane is a medical professional - when I read those notes I'm totally clueless - I fear for other couples who don't have anyone medical in the family, or [don't have access to a lawyer.]'
Having described receiving important pieces of the puzzle in dribs and drabs, Steve and Jane said they were left in a position where they did not know why Bethan died until after her funeral.
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Jane said: 'Bethan's funeral was on March 3 [2020] and I remember being on the phone [to the health board's concerns department] and saying: 'It's Bethan's funeral tomorrow and people will ask how she died and we can't say.'
Even by that point Jane said the family - including Bethan - had never been informed that Bethan had been diagnosed with pneumonia.
The inquest heard how this was a diagnosis given to Bethan during an urgent appointment at Llandough Hospital on January 28, just over a week before she died, but it was not communicated to the family.
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Steve said: 'We didn't know it was pneumonia until… I don't know how long after [she died]. We were in the car when we got the interim post mortem results and it said 'pneumonia'. We looked at each other and said: 'What? Pneumonia?''
The family only learnt about Bethan's pneumonia diagnosis after her death
(Image: Steve James )
Jane added: 'They tried to dismiss it by saying it's the same as a chest infection, but if someone tells you 'pneumonia' - there is a big difference and I think Bethan would have taken more notice of that."
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In the days that followed Bethan continued to feel very unwell and visited A&E at the University Hospital of Wales in Cardiff on a number of occasions.
However, it was heard how medics did not go far enough to investigate her respiratory symptoms, especially within the context of Bethan having Crohn's disease: a chronic inflammatory bowel disease associated with reduced immunity.
The inquest heard a number of disturbing interactions during these hospital visits in which Bethan was verbally dismissed by medics and made to feel like a burden, to the point that she did not want to go into hospital.
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On one occasion it was heard how a consultant at A&E made the comment: 'You again!' It came when Bethan had been advised to return to hospital if her symptoms persisted.
On another occasion a doctor told Bethan about a young female patient he recently saw who had recovered and was 'symptom free'.
Steve and Jane said it was this comment that made Bethan reluctant to go into hospital on the day that she later died. It was also the comment that saw Steve miss Bethan's death, having agreed to work away in Ireland on the basis that his daughter would recover.
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Bethan was the daughter of Glamorgan and England cricket star Steve James
(Image: Steve James )
Steve said this haunts him and led to him developing post traumatic stress symptoms (PTSD).
He said: 'I don't think he realises the impact that comment had on Bethan or on me. That was the reason why I went to Ireland [to report on that] rugby match and that will stay with me for the rest of my life.
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'I'm unable to do my job properly at the moment because I'm unable to go away, I basically have PTSD. Bethan was saying right at the end that Dr Willis said that I'm going to be okay.'
Further detailing his experience of finding out his daughter had died, Steve said: 'That Saturday for me is so traumatic because the weather in Ireland was really bad and the flight could have been cancelled.
"The flight was actually delayed. That meant it was about an hour after Bethan died that I got there.
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'Jane called me a couple of times when I was on my way back and on the M4 somewhere I was told that Bethan had died. I had to pull over and [my friend] had to take over the wheel. I think about that day all the time.
'I wake up sometimes after nightmares where the flight has been cancelled and I am swimming across the sea to try and get back to see Bethan, and it's horrendous.
'It's very hard to talk about to be honest. It is very traumatic and there are feelings of guilt about being away and thinking if I had been there, would I have been able to have convinced Bethan to have gone into hospital on the Friday? Or earlier on Saturday.'
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Bethan had a successful career in journalism ahead of her
(Image: Steve James )
The inquest heard how at around 6pm on Saturday, February 9, 2020, Jane called for an ambulance. But despite Bethan showing clear signs of sepsis - including her blood pressure being 'unrecordable' - paramedics did not "pre-alert" or warn the hospital of Bethan's arrival, leaving medics unprepared.
Knowing what they know now, Steve and Jane said an unrecordable blood pressure is a telltale sign of sepsis which should have resulted in a pre-alert. Steve said the well-known symptom should have been recognised by paramedics as "the reddest of red flags".
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The lack of action from paramedics meant Bethan was taken into the majors department, instead of resus where she could have received more specialist treatment.
It was heard how there was a delay of more than an hour before Bethan was treated in resus, by which point the family say it was 'too late'.
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The parents maintain that Bethan should have been admitted into hospital in the week before her death, recalling how on one occasion she even 'struggled to walk' as she left UHW.
Failing that, they believe there were more opportunities to save Bethan's life on that Saturday.
Steve said: 'She should have definitely been admitted on the Wednesday and if not, the Thursday, and if not on the previous Sunday. There were so many missed opportunities to admit her and I just don't know why they didn't.
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'If you go through from start to finish and see how many mistakes there were, and how many chances there were, it's unbelievable.'
But even after Bethan passed, the family say she continued to be dismissed, claiming that they even heard a nurse refer to her body as 'it'. It is something that the nurse denied during the inquest, but has 'stuck with' the family.
Jane said this had particularly impacted Bethan's then 14-year-old brother Rhys who they say overheard the comment.
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Bethan James wanted to raise awareness of Crohn's and documented her diagnosis on YouTube
(Image: YouTube )
Steve and Jane are now campaigning for Martha's Law to be implemented in hospitals across Wales.
This is a patient safety initiative in English NHS hospitals, granting patients and their families the right to request an urgent review by a critical care outreach team if they are concerned about a patient's deteriorating condition.
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Jane said the family understands that a scheme called Call4Concern is currently being piloted in some Welsh hospitals.
However, when she visited UHW A&E in May 2025 with a family member she said she was appalled to see that 'nothing had changed' in the last five years.
She recalled seeing no posters or leaflets referring to the pilot.
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Paying tribute to her daughter, Jane said: 'Bethan was just a joy all through her life. We keep saying she was the kindest and that's because she was.
'Even from a young age she was kind and considerate. She had that way about her where she always thought of others.
'She was shy growing up until her teenage years when she was 14 and 15 and she became interested in vlogs.
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'At first we were reluctant for her to do that on social media, but we soon realised it was her forte.
'She would film them on all sorts of subjects like mental health, make-up and Crohn's. She really came into her own and she lost that shyness about her.
'She was doing really well with her journalism degree. In that January that's when she did her pitch for [a] BBC Crohn's documentary; off her own back she got in touch with Amy Dowden.'
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Steve added: 'I was amazed when she started doing the vlogs because of her shyness. She had a lot of health problems growing up that she fought through, but it obviously added a real inner steel to her.
'Those vlogs revealed a side of her that I wasn't aware of previously. The Crohn's diagnosis hit her hard but she was then determined to raise awareness through the Crohn's and colitis [charities]. She was always thinking of others - that sums up her character.
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'At the end of her life she almost felt like a burden, because she was always thinking of others. She was such a kind and caring soul.'
Bethan was a 'kind and caring soul', her family said
(Image: Steve James )
A Welsh Government spokesman said: 'Ensuring the voices of patients and their loved ones are heard, is paramount to us.
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'To improve patient safety across Wales, we're working with NHS organisations to identify the best patient and family-initiated escalation model. Call4Concern is one scheme being piloted by a number of health boards in Wales and has seen positive steps in improving patient safety.
'We are also implementing phase one of our patient safety plan to ensure people of all ages have an evidence-based early warning scoring system, which will help clinical staff identify deteriorating patients earlier."
The coroner's office said: 'In relation to your request for a comment in relation to this inquest hearing, I respectfully refer you to Page 16 of the Guide to Judicial Conduct 2023 (attached), providing details on why a coroner (as a Judge) would be in breach of the Code for Judicial Conduct and liable to disciplinary action were they to comment publicly on individual judicial decisions.'
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A spokesman for the health board said: 'Our deepest sympathies and heartfelt condolences remain with Bethan's family and loved ones at this difficult time. The health board provided a comprehensive written response to the coroner's request for additional information within the seven-day deadline.
"We are unable to provide further comments until the coroner has reviewed the supplementary evidence."
Liam Williams, the Welsh Ambulance Service's executive director of quality and nursing, said: 'On behalf of everyone at the Welsh Ambulance Service, I would like to extend my deepest sympathies to Bethan's family through what continues to be a difficult time, and offer a renewed apology for the errors which were identified in Bethan's case.
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'While we cannot change the outcome, we remain a learning organisation and are sincerely grateful to the coroner for her thorough examination of this tragic case.
"As a trust, we have taken steps to ensure that the learning we identified at the time were considered and changes implemented.
'This includes the introduction of the electronic patient clinical record, which enables crews to capture a patient's information on an iPad in order to pre-alert healthcare partners prior to a patient's arrival at hospital, and share the documentation of clinical assessment and care given.
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'Our invitation to meet with Bethan's family remains open should they have any outstanding questions or areas that they would like to speak with us about.'