Hospital failings contributed to the death of an otherwise healthy man
Inquests and Inquiries, Health and Social Care
An inquest has found that failings by doctors at a major hospital trust materially contributed to the death of a man in his 40s.
The man (NX) was admitted to hospital (“the receiving hospital”) following a motorcycle accident. He was given an x-ray and CT-scan then transferred to another hospital for specialist treatment (“the treating hospital”). After he was discharged from hospital, while recovering at home, NX began to feel pains in the affected leg and raised concerns with his doctors that a clot had developed. The doctors at the treating hospital did not see evidence of a clot.
The following week, NX died of a pulmonary embolism. The Coroner found that this was, on the balance of probabilities, caused by a clot that developed in NX’s leg. The ambulance service did not have sufficient enough ambulances available to meet demand that evening and paramedics did not attend for nearly an hour. The Coroner, however, concluded that this did not materially contribute to NX’s death because, once the blood clot reached his heart, it was unlikely that paramedics would have been able to assist even if the service had met its response target times.
The Coroner initially refused to call expert evidence on the question of when the blood clot developed. Before the first hearing, however, the receiving hospital disclosed the results of the CT-scan. These indicated the possible presence of a clot. The receiving hospital did not, however, alert either the treating physicians at the treating hospital, or NX himself. On the application of NX’s family, the coroner adjourned the first hearing and instructed an expert. The expert concluded that the clot identified in the CT-scan was likely the clot that caused or contributed to the fatal pulmonary embolism.
Sam Fowles acted for NX’s family in the (adjourned) first inquest and at the final three-day inquest. NX’s family said the following of Sam’s handling of the case: Sam’s “tenacity, subject-matter expertise, and experience were vital but his empathetic human approach, good humour, and willingness to listen sets him apart.”
