David Horsman, of Marsham Road, Westhoughton, died at Royal Bolton Hospital on March 28, 2022 – a day after receiving a CT scan on a mobile unit in the hospital car park as part of a routine check-up following a battle with bowel cancer. and just a month after his 25th wedding anniversary.
This is coverage from the last day of the investigation. Find coverage from day one of the investigation here. You can find coverage from the second day of the investigation here. You can find coverage of the third day of the investigation here. Transcripts and recordings of emergency calls can be found here.
An inquest into his death closed today (Tuesday, May 28) and the coroner ruled his death an accident contributed to by neglect.
As part of David’s CT scan – which took just 65 seconds – Mr Horsman was injected with a “contrast dye” – used to highlight the areas of the body being scanned.
Immediately after the scan, David began to suffer a rare allergic reaction, becoming hot, coughing and flushed.
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Although radiographer Idongesit Okon and colleague Shazia Hanif recognized he was suffering an adverse reaction, Coroner John Pollard said they “did nothing quick to rectify” the situation – instead discussing a possible reaction with him.
As the situation began to deteriorate, Mr. Okon tried to call a radiologist who was summoned, but there was no answer.
He then called the hospital’s emergency number ‘2222’, where he reached switchboard operator Anne Parker.
In the call, Ms Parker asks if this is a “cardiac arrest on E5” emergency – referring to an area in the hospital’s children’s ward – despite Mr Okon saying several times that the emergency happened in a “CT van”.
It is only when Mr. Okon calls a third time that Ms. Parker realizes the mistake, who – minutes later – tells the hospital operator that it was Mr. Okon who made the mistake and tells the ambulance operator that Mr. Okon “didn’t.” speak a lot of English’.
The operator of the call “set the chain of events in motion”
Coroner John Pollard said it was true that Mr Okon had a “quite thick accent” and that he “talked quite fast”.
But the coroner denied Ms Parker’s claim that he spoke “limited English”, adding that while he did not follow the approved script, he “clearly stated the problem area”.
The coroner went on to say that Mr Okon’s repeated phone calls to Ms Parker received a “somewhat terse and unhelpful response”, adding that Ms Parker “demonstrated a lack of patience and clarity” in the call.
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Coroner Pollard added that Ms Parker’s mistake “set in motion a chain of events” that led to David’s death.
In addition, the coroner said the hospital’s system “may be faulty” as a result of staff not being able to contact the radiographer on call.
Staff were trained to use EpiPens – but none were available in the van, despite the company that ran the van – InHealth – requesting them from the hospital. The EpiPena was provided to the van just days after Mr Horsman’s death.
In a false alarm following this incident, the hospital’s emergency team took just three minutes to arrive at the scene.
Mr Pollard assessed that Mr Horsman had suffered a cardiac arrest six minutes after the first call to the hospital’s 911 line.
Taking into account the communication breakdown, the coroner said there was “evidence to show that Mr Horsman’s life would have been prolonged if the team had crashed him when they should have”, ruling the death an accident contributed by negligence.
The coroner said he would write a letter of concern to the head of Royal Bolton Hospital and the head of InHealth, Joanne Thomas, to find out what special training had been carried out so that all the company’s scanner staff knew how to describe emergencies. and location and for the hospital to “ensure staff are fully trained to calmly take in all details correctly and respond appropriately”.
‘I miss you so much’
Wife Jane Horsman told the court: “He was an absolute character. He stood up and spoke at our silver wedding and I will always cherish that. He was funny, but he was also kind.
“He was the best, I miss him a lot.
Jane added that the CT scan results eventually came back after David’s death.
She said: “The good news is the CT scan results have come back and the cancer has not returned, but sadly David has not – he died in hospital that day.”
Recordings of calls to the hospital’s 911 line were played in court – something Ms Horsman had never heard before.
Jane said it was ‘not easy’ to hear the recordings in court, adding: ‘I got the transcripts beforehand but I didn’t hear them. It was played across the court, it was a crowded courthouse.
“Hearing them, it was really very upsetting.
“We could have got the emergency team to David in the normal three or four minutes, but unfortunately it took 17 minutes due to a lack of communication and that was largely one of the reasons why David died.”
‘Get it together’
Now Jane wants to see Royal Bolton put in place measures to ensure the incident cannot happen again.
She added: “It would be nice if the CEO was in touch with me, of course not.
“What would I say? Get your act together and make sure that when you’re doing the risk assessment and setting up the department, you’re not setting it up to fail.”
Stephen Jones, a partner at Leigh Day, who represented the family at the hearing, said the family was now considering legal action.
And he added: “Neglect at a coroner’s court is a very rare finding. This happens very rarely because it is legally very strictly defined.
“One of the things you have to show is that the failures were gross — not just simple failures where mistakes can be made, but gross failures.
“This failure of communication in terms of how the emergency was communicated, the coroner found it to be a gross failure, and I think he got it absolutely right.”
The hospital trust “fully accepts” the findings
Dr. Francis Andrews, medical director of Bolton NHS Foundation Trust, said in a statement: “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.
“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 roles.
“Nothing we can say or do will spare Mr Horsman’s family from such a devastating outcome and our sympathies remain with them.”
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