A coroner has ruled that neglect contributed to the death of a man who was having a routine scan at the Royal Bolton Hospital after it took 17 minutes for a hospital’s emergency ‘crash team’ to attend to him after suffering an allergic reaction.
David Horsman, of Marsham Road, Westhoughton, died at Royal Bolton Hospital on March 28, 2022 – the day after receiving a CT scan in a mobile unit in the hospital car park as part of a routine check-up following a fight with bowel cancer, and just one month after his 25th wedding anniversary.
This is coverage of the final day of the inquest. Coverage from day one of the inquest can be found here. Coverage from day two of the inquest can be found here. Coverage from day three of the inquest can be found here. Transcripts and recordings from the emergency calls can be found here.
An inquest into his death concluded today (Tuesday, May 28), with the coroner ruling his death as one of misadventure contributed to by neglect.
As part of David’s CT scan – which lasted just 65 seconds – Mr Horsman was injected with ‘contrast dye’ – used to highlight areas of the body that are being scanned.
Immediately after the scan, David started to suffer a rare allergic reaction, feeling hot, coughing, and turning red.
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Despite radiographer Idongesit Okon and colleague Shazia Hanif recognising that he was suffering an adverse reaction, Coroner John Pollard said they did ‘nothing rapidly to remedy’ the situation – instead discussing the possible reaction with him.
When the situation started to deteriorate, Mr Okon attempted to call the on-call radiographer, but there was no answer.
He then called the hospital’s emergency ‘2222’ number, where he got through to switchboard operator Anne Parker.
In the call, Mrs Parker asks whether the emergency is a ‘cardiac arrest on E5’ – referring to an area in the hospital’s paediatric ward – despite Mr Okon stating multiple times that the emergency was happening in the ‘CT van’.
It is only when Mr Okon calls a third time that the error is realised by Mrs Parker, who – minutes later – tells the hospital site operator that it was Mr Okon who made the mistake and tells an ambulance operator that Mr Okon ‘didn’t speak much English’.
Call operator ‘set in motion a chain of events’
Coroner John Pollard said that it was true to say Mr Okon has ‘quite a strong accent’ and that he ‘speaks quite quickly’.
However, the coroner rubbished Mrs Parker’s claims he spoke ‘limited English’, adding that, although he failed to follow the approved script he had ‘clearly stated the location of the problem’.
The coroner went on to say that Mr Okon’s repeated calls to Mrs Parker received a ‘somewhat brusque and unhelpful response’, adding that Mrs Parker ‘demonstrated a lack of patience and clarity’ in the call.
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Coroner Pollard added that Mrs Parker’s error had ‘set in motion a chain of events’ leading to David’s death.
Additionally, the coroner said the hospital system ‘may be flawed’ as a result of staff being unable to contact the on-call radiographer.
Staff were trained to use EpiPens – but none were available in the van, despite the company which operated the van – InHealth – requesting them from the hospital. EpiPens were provided to the van just days after Mr Horsman’s death.
In a false alarm following this incident, the hospital’s crash team took just three minutes to reach the site.
Mr Pollard assessed that Mr Horsman had suffered a cardiac arrest six minutes after the first call to the hospital’s emergency number was made.
Taking into account the breakdown in communication, the coroner said there was “evidence to show Mr Horsman’s life would have been prolonged had the crash team reached him when they should have done”, ruling the death as misadventure contributed to by neglect.
The coroner said he would be writing to the chief of the Royal Bolton Hospital and the lead of InHealth, Joanne Thomas, with a letter of concern to ascertain what extra training had been undertaken to ensure all staff in the company’s scanners know how to describe emergencies and a location, and for the hospital “to ensure staff are fully trained to calmly take all details properly and respond appropriately.”
‘I miss him so much’
Speaking outside court, wife Jane Horsman said: “He was an absolute character. He got up and did a speech at our silver wedding and I’ll always keep that. He was funny but he was lovely as well.
“He was the best, I miss him so much.”
Jane added that the CT scan results eventually came back following David’s death.
She said: “The good news is, the CT scan results came back and his cancer hadn’t returned, but unfortunately David didn’t return – he died at the hospital that day.”
In court, recordings of the calls to the hospital’s emergency number were played – something Mrs Horsman had not heard before.
Jane said it ‘wasn’t easy’ to hear the recordings in court, adding: “I had received the transcripts beforehand, but I hadn’t heard them. It was played across court, it was a packed courthouse.
“To actually hear them, it was really quite upsetting.
“We could have got the crash team to David within the normal three or four minutes, but unfortunately because of the lack of communication it took 17 minutes and that was predominantly one of the reasons David passed away.”
‘Get your act together’
Now Jane wants to see Royal Bolton putting measures in place to ensure there can’t be a repeat of the incident.
She added: “It would have been nice if the CEO had been in touch with me, obviously not.
“What would I say? Get your act together, ensure that when you’re producing risk assessments and you’re setting departments up that you don’t set it up to fail.”
Stephen Jones, a partner at Leigh Day, who represented the family at the hearing, said the family would now be considering legal action.
He added: “Neglect in the coroner’s court is a very rare finding. It happens very rarely because it’s very tightly defined legally.
“One of the things you have to show is that the failures have been gross – not just simple failures where mistakes can be made, but gross failures.
“That breakdown of communication in terms of how the emergency was communicated, the coroner found to be a gross failure, and I think he was absolutely right to do so.”
Hospital trust ‘fully accepts’ findings
In a statement, Dr Francis Andrews, medical director at Bolton NHS Foundation Trust, said: “I would like to extend my sincere condolences to Mr Horsman’s family, as they continue to come to terms with such a tragic loss.
“We fully accept the findings of the inquest and our commitment to the family and all who knew him is to make sure that we learn and do as much as we possibly can to prevent such a tragedy from happening again.
“We no longer commission private providers for radiology services; have continued to run simulation exercises related to identifying and managing anaphylaxis with our existing and new radiology staff; and all call handlers working in our switchboard service have taken part in extensive training before being able to continue in their roles.
“Nothing we can say or do will take away from such a devastating outcome for Mr Horsman’s family, and our sympathies remain with them.”
If you have a story, I cover the whole borough of Bolton. Please get in touch at jack.fifield@newsquest.co.uk.
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