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Nurse Panicked, Failed to Save Patient
18 Aug
Summary
- A nurse panicked and made poor decisions after finding a patient unresponsive.
- Resuscitation guidelines were not followed, and no cardiac arrest call was made.
- The patient's unexpected death was not reported to the coroner by doctors.
A patient's death at Glan Clwyd hospital last year is under scrutiny following an inquest into the care provided by agency nurse Joseph Kamangire. Kamangire found Mohammed Jaafri, a former furniture dealer, cold and unresponsive in his room on April 21, 2025, at 06:30 GMT. Despite Jaafri not having a "do not attempt CPR" request and his death being unexpected, Kamangire admitted to panicking and making "bad decisions," failing to initiate resuscitation or issue a cardiac arrest call.
The Betsi Cadwaladr University Health Board has accepted that resuscitation should have been attempted and that opportunities for crucial observations were missed. The coroner noted a "significant deviation" from expected care standards and "missed opportunities." Alarmingly, Jaafri's death was not reported to the coroner or medical examiner by hospital doctors. The coroner is considering issuing a Prevention of Future Deaths report. Jaafri's probable cause of death was bronchopneumonia due to flu and frailty.
