A retired engineer who had an allergic reaction to a CT scan was let down as hospital failings contributed to his death, an inquest has revealed.
Grandfather David Horsman had a cardiac arrest following a reaction to a routine scan in a facility at the Royal Bolton Hospital. But a breakdown in communication between the radiographer conducting the scan and the switchboard operator led to a 17-minute delay in the hospital crash team reaching him.
A three-day inquest heard the team of medics were able to resuscitate him, but he died the following day. An independent medical expert told the hearing that with prompt and appropriate care his death would probably have been avoided.
David, 65, from Westhoughton, visited a mobile CT scanner, owned and staffed by private firm InHealth, situated in a car park of the hospital on March 27, 2022, for a scan which was part of the follow-up care to successful surgery for bowel cancer. He had a contrast medium injected into him and underwent the scan that lasted just over a minute. He began to feel ill shortly afterwards, as he began coughing and his skin reddening.
Assistant coroner John Pollard (Manchester Evening News)Assistant Coroner John Pollard said: "As he was obviously worsening, the staff tried to call the on-call Radiologist, but there was no answer. The staff on the van did not have the auto-injectors of adrenaline available to them and were not trained to draw up and inject the ampules stored on the vehicle.
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"A call was made to the hospital by using the 2222 emergency number and although the radiographer did not follow the exact script, he did give all the relevant information to the telephone operator. The operator did not clarify the exact location and in fact mistakenly introduced the notion that the patient was in the Paediatric Ward.
"This set in place a chain of events that caused there to be a 17-minute delay in the crash team being present."
A pathologist gave his cause of death as 1A) anaphylactic shock and 2) Ischaemic heart disease. Mr Pollard gave a conclusion that his death was misadventure, contributed to by neglect, Manchester Evening News reports.
David's wife Jane now says she and her family are 'appalled' at how the hospital 'let down' her late husband. Speaking following the inquest, Jane said: “David went to the hospital for a routine scan and I stayed home because of covid restrictions still in place at Royal Bolton Hospital. We had no qualms about the procedure and spent the time preparing for a holiday we were about to take.
“I was horrified to receive the call that David had had a reaction to the CT scan procedure, and by the following day my world had been tipped upside down. After David was making a good recovery from the bowel cancer three years earlier, his death was completely unforeseen. To lose him when we were at the start of our retirement has been and continues to be devastating.
“To hear of the circumstances surrounding David’s death, the failings at Royal Bolton Hospital, have sickened me. I expected that David would be safe and would have trusted the hospital staff to take good care of him if something went wrong. Something did go wrong, but the hospital let David and his family down. I am appalled.
“I am grateful to the coroner for his careful consideration of what happened on the day before David died. I am also grateful for Leigh Day’s Stephen Jones’ work and support on my case in allowing me to achieve justice for what happened to David.”
Stephen Jones, from legal firm Leigh Day, who represented the family, said: “Listening to the call recordings being played in court and hearing how things went so tragically and unnecessarily wrong was very upsetting.
"The process for calling the crash team was quite straightforward but was simply not handled properly. The crash team were reduced to roaming the hospital to try to locate the emergency, and when they finally came across David it proved to be too late to save him. David’s death should have been avoided.”
The Royal Bolton Hospital said key changes had now been made to their procedures following the tragedy. Dr Francis Andrews, Medical Director at Bolton NHS Foundation Trust, which runs the hospital, 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.
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“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 role. 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.”
An InHealth spokesman said: "As a healthcare provider dedicated to delivering the very best care to our patients, we are deeply saddened that this unexpected death occurred and send our sincerest condolences to Mr Horsman’s family.
"As with any incident, but particularly in this case, 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 that we reduce the risk of an incident such as this from happening again.
"As a learning organisation with a culture of ongoing development and understanding, we support all our colleagues in learning from incidents and we 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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