The widow of a retired engineer who suffered a fatal allergic reaction to a CT scan says she is ‘sickened’ by hospital failings a coroner has found contributed to his death.
Grandfather David Horsman, 65, from Westhoughton, suffered a cardiac arrest after having a reaction to a routine scan at a facility at the Royal Bolton Hospital.
An inquest into his death which concluded last week heard a breakdown in communication between the radiographer carrying out the scan and the switchboard operator led to a 17-minute delay in the accident team arriving at the hospital.
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They were able to revive him, but he died the next day. The inquest heard medical evidence from independent experts that with prompt and appropriate care his death could probably have been avoided.
And after a three-day hearing which ended last week, a coroner concluded that his death was the result of an accident caused by negligence.
David visited a mobile CT scanner, owned and staffed by private firm InHealth, located in a hospital car park on March 27, 2022, for a scan which was part of the follow-up care to successful bowel cancer surgery.
He was injected with a contrast medium and underwent a scan that lasted just over a minute. However, he started to feel sick shortly after, as he began to cough and his skin turned red.
Assistant Coroner John Pollard said: “As he was visibly deteriorating, staff tried to call the radiologist on call 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 stored in the vehicle.
“A call was made to the hospital using the emergency number 2222 and although the Radiographer did not follow the script correctly, he gave all the relevant information to the telephone operator.
“The operator did not clarify the exact location and actually mistakenly entered the notion 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 crash team.”
He was revived but died the next day. A pathologist gave the cause of death as 1A) anaphylactic shock and 2) ischemic heart disease. Mr Pollard gave a conclusion that his death was an accident, caused by negligence.
David’s wife Jane now says she and her family are ‘horrified’ at the way the hospital ‘let down’ her late husband. Speaking after the inquest, Jane said: “David went to hospital for a routine scan and I stayed at home due to the COVID restrictions still in place at the Royal Bolton Hospital. We had no qualms about the procedure and spent the time preparing for a party we were about to have.
“I was horrified when I got the call that David had had a reaction to the CT scan procedure and the next day my world was turned upside down.
“After David made a good recovery from bowel cancer three years ago, his death was completely unexpected. Losing him when we were at the beginning of retirement has been and continues to be devastating.
“To hear about the circumstances of David’s death, the failings at the Royal Bolton Hospital, sickened me. I expected David to be safe and I would have trusted the hospital staff to take good care of him if something went wrong. Something went wrong, but the hospital left David and his family. I am terrified.
“I am grateful to the doctor for his careful consideration of what happened the day before David’s death. I am also grateful for the work and support of Leigh Day’s Stephen Jones in my case, allowing me to achieve justice for what happened to David.”
Stephen Jones, of law firm Leigh Day, who represented the family, said: “Listening to the recordings of the calls being played in court and hearing how things went so tragically and needlessly wrong was very distressing.
“The process for calling the crash team was pretty straightforward, but it just wasn’t handled properly. The crash team was reduced to roaming around the hospital trying to find the emergency, and when they finally met David, it turned out that it was too late to save him. David’s death should have been avoided.”
The Royal Bolton Hospital said major 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 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 our commitment to the family and all those who knew him is to ensure that we learn 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 service have attended extensive training before they are 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 condolences go out to them.”
An InHealth spokesperson said: “As a healthcare provider committed to providing the best care for our patients, we are deeply saddened that this sudden death has occurred and send our deepest condolences to Mr Horsman’s family.
“As with any incident, but particularly in this case, we have carried out a full 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 a incident such as this does not happen again.
“As a learning organization with a culture of continuous development and understanding, we support all our colleagues to learn from incidents and have worked very closely with everyone involved in this case to ensure that the measures taken our entire organization.”
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