Fatality ‘inevitable’ at Royal Bolton scanner where man died

A document directed staff in the CT van, which was operated by private company InHealth under contract with the Royal Bolton Hospital, to call the hospital’s emergency 2222 number.

The document said that a doctor ‘must attend within 15 minutes’.

Coroner John Pollard said the document’s advice would ‘almost inevitably lead to fatal consequences’.

This is coverage of day three of the inquest. Coverage of day one is available here. Coverage of day two is available here. Transcripts from the emergency calls are available here.

David Horsman died after suffering from a rare anaphylactic shock brought on by an injection of ‘contrast dye’ – which is used to help highlight areas of the body that are being scanned.

Despite a member of staff making an emergency call to get a hospital ‘crash team’ to David before he suffered a cardiac arrest, a mix-up meant they were sent to a different part of the hospital, with Mrs Parker saying she thought she saw a reference to ward ‘E5’ on her telephone screen.

The court heard how, subsequent to the incident, a crash team responded to a false alarm at the van in a time of just three minutes – much faster than the 17 minutes it took to respond on the day of David’s scan.

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Criminality ‘a very high bar’

Detective Inspector David Sinclair, stationed at Bolton Criminal Investigation Department, told the court how he was asked to conduct a review of the death to see whether there was any criminality – in particular, manslaughter.

An officer for 30 years, DI Sinclair said: “Clearly mistakes were made in the communication of the location and compounded by the actions of Ann Parker when she spoke over the caller and sent the cardiac arrest team to E5.”

Agreeing that criminality was ‘a very high bar’, he added: “We are saying these are errors in communication, misunderstandings, these are not things that would constitute that level of criminality.”

Coroner John Pollard said he was ‘very impressed’ by DI Sinclair’s investigation.

EpiPens not provided

Despite staff in the CT vans being trained to use EpiPens, none were provided for them to use by the Royal Bolton Hospital, which was in charge of the medication being provided in the van.

The court heard that EpiPens were provided eight days following the incident, having previously not been provided due to a ‘national shortage’.

Joanne Thomas, the head of operations at InHealth’s CT division, and herself a qualified radiographer, had previously raised concerns over potential emergency response times to the CT van.

In an email chain, Ms Thomas had urged the procedure to be changed from the van ringing 999 to instead ringing the hospital’s internal emergency ‘2222’ number.

Referring to 999 response times, in her email she says “eight minutes is a long time for anaphylaxis.”

Dr Amanda Law, a consultant radiologist at the Royal Bolton since 2008, was questioned over the lack of EpiPens.

Dr Law said EpiPens were not the solution, with issues such as operators accidentally injecting themselves.

Instead, Dr Law said, all staff should be trained to inject adrenaline from ampoule vials.

Dr Law said: “That’s one of the areas we want to work towards, to upskill the staff to inject with a non-automated injector, just a needle and syringe.”

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‘Largest part of error on behalf of call operator’

In the hospital’s own ‘serious untoward incident’ report, authored by Dr Law, radiographer Idongesit Okon was criticised for not using the correct script when making the emergency ‘2222’ call.

Coroner John Pollard, however, took a different view, saying: “I think the emphasis here is wrong, would you agree? It’s saying here the external radiographer had made the mistake.”

Dr Law, however, said that the switchboard operator, Mrs Parker, would not have been used to hearing this information and was not trained to understand what a ‘contrast reaction’ was, and that Okon should have instead said ‘A block’.

However, Coroner Pollard pointed out that ‘E5’ had never been mentioned before Mrs Parker said it.

He added: “I’d like to suggest to you that the largest part of the error was on behalf of the call operator.”

He added that he would include that Mr Okon was clear in his findings.

The court heard that the department has now been brought in-house, with more experienced ‘band 7’ staff always supposed to be available in the sessions, which are now carried out in the hospital building.

At the end of her testimony, Dr Law addressed the family directly, adding: “I have made a lot of effort to improve the department, because I’m constantly thinking about you.”

The inquest continues.

If you have a story, I cover the whole borough of Bolton. Please get in touch at jack.fifield@newsquest.co.uk.