The widow of a retired engineer who suffered a fatal allergic reaction to a CT scan says she is “disgusted” by hospital failings a coroner found contributed to his death.
Grandfather David Horsman, 65, from Westhoughton, suffered a cardiac arrest after having a reaction to a routine scan at the facility at Royal Bolton Hospital.
An inquest into his death, which ended last week, heard a communication breakdown between the radiographer carrying out the scan and the switchboard operator led to a 17-minute delay in getting to him by the hospital’s accident team.
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He managed to resuscitate him, but he died the next day. The inquest heard independent expert medical evidence that his death would likely have been avoided with prompt and appropriate care.
And after a three-day hearing, which ended last week, the coroner concluded that his death was the result of an accident compounded by neglect.
On March 27, 2022, David visited the mobile CT scanner, owned and operated by the private company InHealth, located in the hospital parking lot, for a scan that was part of the follow-up care after successful colon cancer surgery.
He was injected with contrast material and underwent an examination that lasted just over a minute. However, shortly afterwards he started to feel sick as he began to cough and his skin turned red.
Assistant Coroner John Pollard said: “As he was clearly deteriorating, staff tried to call a radiologist who was called but there was no answer.
“Employees in the van did not have adrenaline auto-injectors available and were not trained to collect and inject ampoules stored in the vehicle.
“A 2222 emergency call was made to the hospital and although the radiologist did not follow the exact script, he provided the operator with all the relevant information.
“The operator did not specify the exact location and in fact mistakenly introduced the idea that the patient was in the Children’s Ward. This set off a chain of events that caused a 17-minute delay in the presence of the impact team.” “
He was resuscitated but died the next day. The pathologist listed his cause of death as 1A) Anaphylactic Shock and 2) Ischemic Heart Disease. Mr Pollard concluded that his death was an accident contributed to by neglect.
David’s wife Jane now says she and her family are “horrified” at how the hospital “let down” her late husband. After the inquest, Jane said: “David went to hospital for a routine check-up and I stayed at home due to covid restrictions at the Royal Bolton Hospital. We had no qualms about proceeding and spent the time preparing for the vacation we were about to take.
“I was horrified when I got the call that David had responded to the CT scan and the next day my world was turned upside down.
“After David had made a good recovery from colon cancer three years earlier, his death was completely unexpected. Losing him when we were at the start of our retirement was and still is devastating.
“When I heard about the circumstances of David’s death, about the failings at Royal Bolton Hospital, I felt sick. I expected David to be safe and trust 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 horrified
“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 get justice for what happened to David.
Stephen Jones, from law firm Leigh Day, who represented the family, said: “Listening to the recordings of the calls played in court and hearing how things went so tragically and needlessly wrong was very upsetting.
“The process of calling the emergency team was quite simple, but it just wasn’t handled correctly. The emergency team had to wander around the hospital to try and locate the emergency room, and when they finally came across David, it was too late to save him.” David’s death should have been prevented.’
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 offer 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 everyone who knew him is to ensure that we learn the lessons and do as much as possible to prevent such a tragedy from happening again.”
“We no longer commission private providers for radiology services; continued to conduct simulation exercises related to the identification and management of anaphylaxis with our existing and new radiology staff; and all call handlers working in our switchboard have undergone extensive training before continuing in their role.
“Nothing we can say or do will spare Mr Horsman’s family from such a devastating outcome 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 offer our sincere 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, have put measures in place to address the specific circumstances to ensure we reduce the risk of the incident, such as preventing it from happening again.
“As a learning organization with a culture of continuous development and understanding, we support all of our colleagues in learning from incidents and have worked very closely with everyone involved in this case to ensure that the actions taken are embedded across our organisation.”
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