The widow of a retired engineer who suffered a fatal allergic reaction to a CT scan says she is ‘tormented’ by hospital failings which a coroner found contributed to his death.
Grandad David Horsman, 65, from Westhoughton, went into cardiac arrest after responding to a routine scan at the facility at Royal Bolton Hospital.
An inquest into his death, which concluded last week, revealed a breakdown in communication between the radiographer carrying out the scan and the switchboard operator led to a 17-minute delay in the hospital’s accident team getting to him.
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They managed to resuscitate him, but he died the next day. The inquest heard independent expert medical evidence that with prompt and appropriate care his death would likely have been avoided.
And after a three-day inquest that ended last week, the coroner ruled his death the result of an accident contributed by negligence.
On March 27, 2022, David visited a mobile CT scanner, owned by the private company InHealth, located in the hospital parking lot, for imaging as part of follow-up care after successful bowel cancer surgery.
He was injected with a contrast medium and underwent imaging that lasted a little over a minute. However, not long after that he began to feel ill as he began to cough and his skin turned red.
Assistant Coroner John Pollard said: «As he was clearly deteriorating, staff tried to call the radiologist on duty but there was no answer.
«The personnel in the van did not have adrenaline auto-injectors available and were not trained to extract and inject the ampoules that were stored in the vehicle.
“The hospital was referred via the emergency number 2222 and although the radiographer did not follow the exact script, he gave all the relevant information to the telephone operator.
«The operator did not clarify the exact location and in fact mistakenly introduced the idea that the patient was in the Pediatric Ward. This set off a chain of events that caused a 17-minute delay in the arrival of the accident team.»
He was resuscitated, but died the next day. The pathologist stated 1A) anaphylactic shock and 2) ischemic heart disease as the cause of death. Mr Pollard concluded that his death was an accident, to which neglect contributed.
David’s wife Jane now says she and her family are ‘appalled’ by how the hospital ‘failed’ her late husband. Speaking after the inquest, Jane said: “David went to hospital for a routine check-up and I stayed at home due to the restrictions still in place at the Royal Bolton Hospital. We had no doubts about the procedure and we spent the time preparing for the annual vacation that we were supposed to spend.
“I was horrified when I got the call that David had a reaction to the CT scan and the next day my world was turned upside down.
«After David had made a good recovery from bowel cancer three years earlier, his death was completely unexpected. Losing him at the start of our retirement was and continues to be devastating.
“I’m sick of hearing about the circumstances of David’s death, the failings at the Royal Bolton Hospital. I expected David to be safe and I trusted the hospital staff to take good care of him if anything went wrong. Something went wrong, but the hospital failed David and his family. I am appalled.
“I am grateful to the coroner for his careful consideration of what happened the day before David’s death. I am also grateful for the work and support of Stephen Jones of Leigh Day in my case which enabled me to achieve justice for what happened to David.”
Stephen Jones, of law firm Leigh Day, who represented the family, said: “Listening to the tapes of the calls that were played in court and hearing how things had gone so tragically and needlessly wrong was very distressing.
«The process of calling the accident team was quite simple, but it just wasn’t done correctly. The accident team had to wander around the hospital to try and locate an ambulance, and when they finally came across David, it turned out to be too late to save him .the death of David should have been avoided.”
Royal Bolton Hospital said key changes have now been made to their procedures following the tragedy. dr. Francis Andrews, medical director of Bolton NHS Foundation Trust, which runs the hospital, said: «I would like to express 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 it is our commitment to the family and everyone who knew him to make sure we learn and do as much as possible to prevent such a tragedy from happening again.
«We no longer commission private radiology providers; we continued to conduct simulation exercises with our existing and new radiology staff regarding the identification and management of anaphylaxis; and all call handlers working in our head office have undergone extensive training before they can continue in their role.
«Nothing we can say or do will affect such a devastating outcome for Mr Horsman’s family and our sympathies remain with them.»
An InHealth spokesperson said: «As a healthcare provider dedicated to providing the best care to our patients, we are deeply saddened that this unexpected death has occurred and send our deepest condolences to Mr. Horsman’s family.
«As with any incident, but in this case in particular, we have carried out a thorough review of our CT services and following Mr Horsman’s death, we have implemented measures to address the specific circumstances to ensure we reduce the risk of an incident such as this not happening again .
«As a learning organization with a culture of continuous development and understanding, we support all our colleagues in learning from incidents and have worked very closely with everyone involved in this case to ensure that the measures taken are embedded across our organisation.»
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