David Horsman, of Marsham Road, Westhoughton, died at Royal Bolton Hospital on March 28, 2022 – a day after receiving a CT scan in a mobile device in the hospital car park as part of a routine check-up after battling bowel cancer, and just one month after his 25th wedding anniversary.
This is a report from the last day of the investigation. A report from the first day of the investigation can be found here. A report from the second day of the investigation can be found here. A report from the third day of the investigation can be found here. Transcripts and recordings of the emergency calls can be found here.
An inquest into his death closed today (Tuesday, May 28) with the coroner ruling his death as an accident caused by negligence.
As part of David’s CT scan – which lasted 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, feeling hot, coughing and turning red.
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Although radiologist Idongesit Okon and his colleague Shazia Hanif admitted he was suffering an adverse reaction, Coroner John Pollard said they did “nothing quickly to correct” the situation – instead discussing the possible reaction with him.
When the situation began to deteriorate, Mr. Okon tried to call the radiologist on duty, but there was no answer.
He then called the hospital’s emergency number ‘2222’, where he contacted switchboard operator Anne Parker.
In the call, Ms Parker asks if the emergency was an “E5 cardiac arrest” – referring to an area in the hospital’s pediatric ward – despite Mr Okon repeatedly stating the emergency happened in the “CT suite”.
It was only when Mr. Okon called a third time that the mistake was realized by Ms. Parker, who – minutes later – told the hospital operator that Mr. Okon had made the mistake and told the ambulance operator that Mr. Okon “doesn’t speak much English.”
The operator of the call “triggers a chain of events”
Coroner John Pollard said it was true that Mr Okon had a “quite strong accent” and that he “talked quite fast”.
However, the coroner disputed Ms Parker’s claims that he spoke “limited English”, adding that although he did not follow the approved script, he had “clearly indicated the location of the problem”.
The coroner went on to say that Mr Okon’s repeated calls to Ms Parker received a “somewhat rude and unhelpful response”, adding that Ms Parker “demonstrated a lack of patience and clarity” in the conversation.
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Coroner Pollard added that Mrs Parker’s mistake “triggered a chain of events” which led to David’s death.
The coroner also said the hospital’s system “may have been flawed” as a result of staff not being able to contact the on-call radiologist.
Staff were trained to use EpiPens – but none were available in the van, even though the company that runs the van – InHealth – requested them from the hospital. EpiPens were provided on the van just days after Mr Horsman’s death.
In a false alarm following this incident, the hospital’s crash team took only three minutes to reach the scene.
Mr Pollard estimated Mr Horsman went into cardiac arrest six minutes after the first call to the hospital’s emergency number.
Noting the breakdown in communication, the coroner said there was “evidence to show that Mr Horsman’s life would have been prolonged if the crash team had reached him when they should”, ruling the death an accident caused by carelessness.
The coroner said he would write to the head of the Royal Bolton Hospital and the head of InHealth, Joan Thomas, with a letter of concern to find out what additional training had been undertaken to ensure all staff at the company’s scanners knew how to describe emergencies and location, and for the hospital to “ensure that staff are fully trained to calmly take all details correctly and respond appropriately”.
‘I miss him so much’
Speaking to the court, wife Jane Horsman said: “He was an absolute character. He stood up and gave a speech at our silver wedding and I will always treasure him. It was funny, but it was also wonderful.
“He was the best, I miss him so much.”
Jane added that the CT scan results eventually came back after David’s death.
She said: “The good news is the CT scan results came back and his cancer hadn’t come back, but sadly David didn’t – he died in hospital that day.”
Records of calls to the hospital’s emergency number were played in court – something Ms Horsman had not heard before.
Jane said it was ‘not easy’ to listen to the recordings in court, adding: ‘I had received the transcripts beforehand but I hadn’t heard them. It was played across the court, the court was full.
“To hear them was really quite upsetting.
“We could have sent the crash team to David within the normal three or four minutes, but unfortunately because of the lack of communication it took 17 minutes and that was primarily one of the reasons why David died.”
Get yourself together
Jane now wants to see Royal Bolton put measures in place to ensure the incident doesn’t happen again.
She added: “It would have been nice if the chief executive had contacted me, but apparently not.
“What would I say? Get your act together, make sure that when you’re doing risk assessments and creating departments, 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 would now consider legal action.
He added: “Contempt in a court of law is a very rare occurrence. It happens very rarely because it is very strictly defined by law.
“One of the things you have to show is that the failures were gross — not just ordinary failures where mistakes can be made, but gross failures.
“That breakdown in communication in terms of how the emergency was communicated, the investigator found to be a gross failure, and I think he was absolutely right to do so.”
The hospital trust “fully accepts” the findings
In a statement, Dr Frances Andrews, medical director of Bolton NHS Foundation Trust, 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.
“We fully accept the findings of the investigation and our commitment to the family and everyone who knew him is to make sure we learn and do as much as we can to prevent a tragedy like this from happening again.”
“We no longer outsource radiology services to private providers; continued to conduct simulation exercises related to the identification and management of anaphylaxis with our existing and new radiology staff; and all call operators working in our central service have taken part in extensive training before they can continue in their roles.
“Nothing we can say or do will change such a devastating outcome for Mr Horsman’s family and our sympathies remain with them.”
If you have a story I cover the whole Borough of Bolton. Please contact jack.fifield@newsquest.co.uk.