“HE SHOULD not have died.”
That is the damning verdict from a Southampton coroner looking into the death of David Adams at Southampton General Hospital.
The dad-of-three unexpectedly died four days after slipping in the bathroom at his Hedge End home, hitting his side on the toilet as he fell.
His heartbroken family believe he deserved better treatment – and coroner Keith Wiseman concluded he should not have died from his injuries.
And it is not the first time the coroner has raised concerns about care received at the hospital.
Within the last three weeks, the Daily Echo has reported that Mr Wiseman found the hospital had fallen “well below” the standard of care cancer patient Nigel James, 67, was entitled to.
And when considering the death of Hazel Ladbrooke, 57, he concluded that “important issues” had been raised about defective hospital equipment which “might affect other cases”.
Today Harry Dymond, chairman of patient group Southampton LINk, expressed his concerns and urged that staff at all levels learn the lessons to avoid such “distressing events”.
Southampton Coroner’s Court heard last week how 53-year-old David Adams, who had received heart surgery three years earlier, injured himself in a bathroom fall on November 15, 2011.
He was taken to the Emergency Department at Southampton General Hospital but was discharged after an X-ray revealed no internal bleeding but possible fractured ribs.
The next day his wife returned home from work to find her husband in pain and breathing with difficulty.
His GP Dr Peter Das, from the West End Surgery, visited, prescribed pain killers and urged him to drink fluids.
With no improvement by mid-afternoon on November 18, Mrs Adams called Dr Das, who recommended further fluids as Mr Adams had not passed urine now for at least 24 hours.
However, during his evidence Dr Das accepted that he had not clearly explained to Mrs Adams that he had significant concerns at the time of the call about Mr Adams’ lack of urine output.
He expected her to call back within an hour or two so Mr Adams could be admitted to hospital, but he failed to tell her that and Mr Adams continued to struggle until later that evening when an ambulance was called.
He was readmitted to the Emergency Department at 1.24am, on November 19, when doctors discovered internal bleeding and drained his chest.
Blood tests were immediately taken but the results did not come back until approximately five hours later – which Dr Nick Maskery, lead consultant of the department, described as “quite a considerable delay”.
He added that his experience would have told him to begin treating for renal failure before the results came back. However the doctor on duty waited for the results instead.
Mr Adams also required fluids but notes revealed that the first litre was not given quick enough and there was no evidence of any more being administered after.
Dr Maskery said he felt the importance of adequate fluids had not been appreciated and another consultant, Dr David Weeden, said he would have used a catheter and pushed fluids in a lot quicker.
In addition, notes concerning Mr Adams’ blood content were described as “shambolic” by independent expert Dr Edmund Neville.
He described how the notes concerning another patient had found their way into Mr Adams’ file.
The inquest heard how Mr Adams’ notes also described him as “fully treated” at the time he was being prepared to be transferred to the Cardiac High Dependency Unit.
Dr Maskery questioned this wording.
Mrs Adams herself described almost humorous conversations with a doctor and nurse, indicating their belief that Mr Adams was not in a life-threatening condition.
Both Mr Weeden and Dr Maskery stated that there was a failure to recognise how ill Mr Adams was, but that they would not have predicted the eventual outcome.
Mr David Weeden said that he shared the view that the “warning signs were there and they did need to be picked up”.
As the blood results were received, Mr Adams suffered a cardiac arrest and despite “frantic efforts” to save him, he was pronounced dead at 7.30am on November 19.
The coroner, who said this was a “worrying case”, concluded: “The abnormal results from his blood tests taken on admission were not available for many hours beyond a reasonable time span and in the meantime he did not receive sufficient fluid resuscitation and other general treatment and monitoring consistent with his condition, so that he went into renal failure which led directly to his irrecoverable cardiac arrest.”
He also states that there was no urgency in the care of Mr Adams, adding: “I do not believe for one moment on the evidence that I have received that anyone assisting in the care of Mr Adams throughout this whole period felt that they were dealing with a situation that was potentially fatal.
“Mr Adams was a relatively young man at the date of his death and one has to be left as one’s final thought with the fact that he should not have died from the problems that he had, even given his additional historical vulnerability; this aspect of the matter will no doubt be taken further beyond today.”
FAMILY REACTION
THE FAMILY of David Adams said that they would need time to absorb the verdict before making any decision on legal action.H
is wife Gail said: “I feel Dave died because a number of people in the NHS system didn't do their job properly: from primary care to hospital, it seems the only people who did a good job are the ambulance staff.
“It's truly frightening that so many indications that something was seriously wrong appear to have been missed or ignored.
“With all the knowledge, experience and technology available in the 21st century it seems unthinkable that something as basic as a lack of fluid resuscitation could have contributed so significantly to Dave's death.
“We trusted the judgement of the various medical professionals involved - they let us down.
“The way the hospital dealt with the investigation and reporting following Dave's death is shameful and their resistance to provide medical records and evidence has been appalling.
“I'd like to think lessons can be learned from what happened to Dave so that other people don't die needlessly and other families don't have to suffer as we are.
“However, until the hospital becomes more open and honest about their failings I don't know how they can learn from them.
“Dave deserved so much better than this; we all do.”
HOSPITAL RESPONSE
DR MICHAEL Marsh, medical director at UHS, said: “The treatment Mr Adams received on readmission fell well below the high standards we strive for and expect and we express our deepest sympathies to his family for their sad loss.
"Following this case, the Trust launched an immediate investigation and introduced a number of significant changes to practice around the management of patients with chest injuries on anticoagulants and the process for accurately identifying blood gas samples, while we are also looking into systems that ensure very urgent blood test samples are clearly identified and the results provided in a clinically-appropriate time frame.
“Although we hope the information provided at the inquest helps to give Mrs Adams and her family a clearer understanding of events, we recognise it continues to be an extremely difficult time for them all and would like to offer them our full support with any outstanding issues they have.”
And Mr Adams’ GP, Dr Peter Das, said that he had expressed his condolences and sympathies to Mrs Adams and her family and that he was unable to say any more.
