Your daily adult tube feed all in one place!
Grandfather David Horsman, 65, died due to misadventure contributed to by neglect after suffering allergic reaction to CT scan at NHS hospital, coroner concludes
A grandfather died at an NHS hospital due to misadventure contributed to by neglect after suffering an allergic reaction to a CT scan, a coroner has concluded.
David Horsman, 65, died on March 28, 2022, after he suffered a cardiac arrest in a mobile CT scanner unit located in a car park at the Royal Bolton Hospital.
An inquest heard that a miscommunication between the hospital's switchboard operator and a radiographer conducting the scan 'significantly contributed' to the retired engineer's death.
Bolton Coroners’ Court was told that the radiographer had made an emergency call to the switchboard operator after David suffered an anaphylactic reaction to the contrast dye with which he had been injected with prior to a routine check up.
But the operator sent the hospital's crash team to a children's ward instead of the mobile scanning van after they took down the call incorrectly and misunderstood a further two.
Coroner John Pollard said this miscommunication led to a 'critical delay' in David receiving the appropriate treatment, as he waited for at least 17 minutes after the first call was made.
David Horsman (pictured) died on March 28, 2022, after he suffered a cardiac arrest in a mobile CT scanner unit located in a car park at the Royal Bolton Hospital
An inquest heard that a miscommunication between the hospital's switchboard operator and a radiographer conducting the scan 'significantly contributed' to the retired engineer's death (file image of Royal Bolton Hospital)
Speaking at the conclusion of the inquest on Friday, the coroner said 'the levels, tone and effectiveness of these calls were far below what we would accept as a reasonable standard'.
After the first first call was made, two more calls were made to the call handler by the radiographer, but they continued to misunderstand the correct location of the cardiac arrest call, even though this would have been displayed on her screen.
In the coroner's view, had the correct location been communicated properly to the crash team, they would have been able to arrive to help David before his cardiac arrest, and on the balance of probabilities, he would have survived.
The scan was taking place as a routine check because David was a bowel cancer survivor. He had never previously experienced a reaction during his annual CT scans.
Following the conclusion of the inquest, David's widow Jane Horsman 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.
The inquest in David Horsman's death is being held at Bolton coroner's court (pictured)
'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.'
Jane Horsman was represented at the inquest by Leigh Day clinical negligence partner Stephen Jones.
Stephen Jones 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.'