David Horsman, of Marsham Road, Westhoughton, died at the Royal Bolton Hospital on March 28, 2022 – the day after having a CT scan in a mobile unit in the hospital car park as part of a routine check-up following a battle with bowel cancer , and just a month after his 25th wedding anniversary.
This is the report of the last day of the inquest. Coverage from day one of the survey can be found here. Coverage from day two of the survey can be found here. Coverage from day three of the study can be found here. Transcripts and recordings of the emergency calls can be found here.
An inquest into his death concluded today (Tuesday, May 28), with the coroner ruling his death was an accident caused by neglect.
As part of David’s CT scan – which lasted just 65 seconds – Mr Horsman was injected with ‘contrast dye’, which was used to highlight parts of the body being scanned.
Immediately after the scan, David had a rare allergic reaction: he felt hot, coughed and turned red.
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Despite radiographer Idongesit Okon and colleague Shazia Hanif acknowledging he was suffering from an adverse reaction, coroner John Pollard said they did ‘nothing quickly to remedy the situation’ – instead discussing the possible response with him.
When the situation began to deteriorate, Mr. Okon tried to call the radiologist on duty, but there was no answer.
He then called the hospital’s emergency number 2222, where he spoke to operator Anne Parker.
In the phone call, Ms. Parker asks if the emergency is a “cardiac arrest at E5” – referring to an area in the hospital’s pediatric ward – despite the fact that Mr. Okon has stated several times that the emergency occurred in the “CT- bus’.
It is only when Mr Okon calls for the third time that the mistake is realized by Mrs Parker, who – minutes later – tells the hospital operator that it was Mr Okon who made the mistake and tells an ambulance operator that the Mr Okon ‘did not do that’. speak a lot of English’.
Call operator ‘initiates chain of events’
Coroner John Pollard said it was true to say that Mr Okon has ‘quite a strong accent’ and that he ‘speaks quite quickly’.
However, the coroner denied Ms Parker’s claims that he spoke ‘limited English’, adding that although he failed to follow the approved script, he had ‘clearly identified the location of the problem’.
The coroner further said that Mr Okon’s repeated calls to Ms Parker received a ‘somewhat abrupt and unhelpful response’, adding that Ms Parker ‘demonstrated a lack of patience and clarity’ in the call.
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Coroner Pollard added that Mrs Parker’s mistake had ‘set in motion a chain of events’ that led to David’s death.
In addition, the coroner said the hospital system “may be flawed” because staff cannot contact the radiographer on duty.
Staff were trained in how to use EpiPens, but none were available in the van, despite the company operating the van – InHealth – requesting them from the hospital. EpiPens were delivered to the van just days after Mr. Horsman’s death.
A false alarm following this incident took the hospital crash team just three minutes to reach the location.
Mr Pollard determined that Mr Horsman had gone into cardiac arrest six minutes after the first call to the hospital emergency number.
Taking into account the communications breakdown, the coroner said there was “evidence to show that Mr Horsman’s life would have been prolonged if the crash team had reached him when they should have”, ruling that the death was a was a misfortune caused by neglect.
The coroner said he would write to the head of Royal Bolton Hospital and InHealth management, Joanne Thomas, with a letter of concern to determine what additional training has been undertaken to ensure all staff are in the company’s scanners knows how to describe emergency situations. and a location, and for the hospital “to ensure that staff are fully trained to calmly record all details appropriately and respond appropriately.”
‘I miss him so much’
Outside the courtroom, wife Jane Horsman said: “He was an absolute character. He stood up and gave a speech at our silver wedding anniversary and I will always remember it. He was funny, but also sweet.
“He was the best, I miss him so much.”
Jane added that the CT scan results eventually came back after David’s death.
She said: “The good news is that the CT scan results came back and his cancer had not returned, but unfortunately David did not return – he died in hospital that day.”
Recordings of the calls to the hospital’s emergency number were played in court – something Ms Horsman had not heard before.
Jane said it was ‘not easy’ to hear the recordings in court, adding: ‘I had received the transcripts in advance but I had not heard them. It was played on the entire field, it was a packed courthouse.
“To actually hear them, it was really quite disturbing.
“We could have gotten the crash team to David in the normal three or four minutes, but unfortunately because of the lack of communication it took 17 minutes and that was mainly one of the reasons why David died.”
‘Act normal’
Now Jane wants Royal Bolton to take action to ensure the incident is not repeated.
She added: “It would have been nice if the CEO had contacted me, obviously not.
“What would I say? When making risk assessments and setting up departments, make sure you don’t fail.”
Stephen Jones, a partner at Leigh Day, who represented the family at the hearing, said the family would now consider legal action.
He added: “Neglect in the coroner’s court is a very rare finding. It happens very rarely because it is legally very tightly defined.
“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 communication breakdown 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 accepts findings ‘completely’
In a statement, Dr Francis Andrews, medical director of Bolton NHS Foundation Trust, said: “I would like to express my sincere condolences to Mr Horsman’s family as they continue to cope with such a tragic loss.
“We fully accept the findings of the inquest and our commitment to the family and everyone who knew him is to ensure we learn and do as much as we can to prevent such a tragedy from happening again.
“We no longer commission private providers for radiology services; have continued to conduct simulation exercises related to identifying and managing anaphylaxis with our existing and new radiology staff; and all call handlers working at our switchboard have undergone extensive training before continuing in their roles.
“Nothing we can say or do can take away such a devastating outcome for Mr. Horsman’s family, and our condolences remain with them.”
If you have a story, I cover the whole Bolton area. Contact jack.fifield@newsquest.co.uk.
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