David Horsman, of Marsham Road, Westhoughton, died at the Royal Bolton Hospital on 28 March 2022 – a day after receiving a CT scan in a mobile unit in the hospital car park as part of a routine check-up following a battle with bowel cancer, just a month after his 25th wedding anniversary.
This is the report of the last day of the investigation. You can find coverage from the first day of the investigation here. You can find the report on 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 concluded today (Tuesday, May 28), with the coroner ruling that the death was the result of an accident caused by negligence.
As part of David’s CT scan – which took just 65 seconds – Mr Horsman was injected with a ‘contrast dye’ – used to highlight the parts of the body being scanned.
Immediately after filming, David began to suffer from a rare allergic reaction, he felt hot, coughed and turned red.
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Despite radiographer Idongesit Okon and colleague Shazia Hanif recognizing he was suffering from an adverse reaction, Coroner John Pollard said they did ‘nothing quickly to remedy’ the situation – instead discussing the possible reaction with him.
When the situation began to deteriorate, Mr. Okon tried to call the radiographer on duty, but there was no answer.
He then called the hospital’s emergency number ‘2222’, where he got a telephone operator, Anne Parker.
In the call, Ms Parker asks if the emergency was a ‘cardiac arrest on E5’ – referring to the area in the hospital’s pediatric ward – despite Mr Okon repeatedly stating 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 Mr. Okon made a mistake and tells the 911 operator that Mr. Okon ‘doesn’t speak much English.’
The call operator ‘started a chain of events’
Coroner John Pollard said it was true to say that Mr Okon had a ‘quite heavy accent’ and was ‘quite a fast talker’.
However, the coroner denied Ms Parker’s claims that he had ‘limited English’, adding that although he did not follow the approved script, he ‘clearly stated the problem area’.
The coroner went on to say that Mr Okon’s repeated calls to Ms Parker received a ‘somewhat harsh 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 Mrs 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 have been flawed’ because staff were unable to contact the on-call radiographer.
Staff were trained to use EpiPens – but none were available in the van, despite the company operating the van – InHealth – requesting them from the hospital. The EpiPens were delivered to the van just days after Mr Horsman’s death.
In a false alarm following this incident, the hospital’s accident team took just three minutes to reach the scene.
Mr Pollard estimated that Mr Horsman went into cardiac arrest six minutes after the first call to the hospital’s 911 number.
Noting the breakdown in communication, the coroner said there was “evidence to show Mr Horsman’s life would have been prolonged if the accident team had got to him when they should have”, concluding the death was an accident contributed to by negligence.
The coroner said he would be writing to the head of the Royal Bolton Hospital and the head of InHealth, Joanne Thomas, with a letter of concern to establish what additional training had been undertaken to ensure all staff at the company’s scanners knew how to describe emergencies and the location, and for the hospital ” to ensure staff are fully trained to calmly accept all details and respond correctly.”
‘I miss her very much’
Speaking outside 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 that. He was funny, but he was also sweet.
“He was the best, I miss him a lot.”
Jane added that the CT scan results finally came back after David’s death.
She said: “The good news is the CT results are in and his cancer hasn’t come back, but sadly David didn’t – he died in hospital that day.”
Recordings of calls to the hospital’s emergency number were played in court – something Ms Horsman had never heard before.
Jane said it was ‘not easy’ to hear the tapes in court, adding: ‘I received the transcripts before but I didn’t hear them. The game was played across the field, the courtroom was packed.
“Hearing them, it was really disturbing.
“We could have sent the accident team to David in the normal three or four minutes, but unfortunately due to a lack of communication it took 17 minutes and that was mainly one of the reasons why David passed away.”
‘Get yourself together’
Now Jane wants to see Royal Bolton put in place measures to ensure the incident doesn’t happen again.
She added: “It would have been nice if the CEO had been in touch with me, but apparently he wasn’t.
“What would I say? Pull yourself together, make sure that when you do risk assessments and set up departments, you don’t set 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: “Neglect at a coroner’s court is a very rare occurrence. It happens very rarely because it is legally very narrowly defined.
“One of the things you have to show is that the failures were big—not just simple failures where you can make mistakes, but big failures.
“That breakdown in communication in terms of how the emergency was communicated, the coroner found it to be a major oversight, and I think he was absolutely right to do that.”
The hospital trust ‘fully accepts’ the findings
In a statement, Dr Francis Andrews, medical director of Bolton NHS Foundation Trust, 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 it is our commitment to the family and everyone who knew him to make sure we learn and do as much as possible to prevent such a tragedy from happening again.
“We no longer commission private radiology providers; we continued to conduct simulation exercises related to the recognition and management of anaphylaxis with our existing and new radiology staff; and all call handlers working in our head office have taken part in extensive training before they can continue in their roles.
“Nothing we can say or do will affect such a devastating outcome for Mr Horsman’s family and our sympathies remain with them.”
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