Coroner says neglect contributed to death of man after routine scan at Royal Bolton Hospital

A coroner has concluded the death of a retired engineer after a routine cancer scan at the Royal Bolton Hospital was due to misadventure contributed to by neglect.

David Horsman, 65, of Westhoughton, died on 28 March 2022 after he suffered a cardiac arrest in a mobile CT scanner unit in the hospital car park.

Concluding a three-day inquest at Bolton Coroners’ Court, Coroner John Pollard said a breakdown in communication between the radiographer conducting the scan and the switchboard operator had led to a critical delay in Mr Horsman being treated in time.

The radiographer made three emergency calls to the switchboard after Mr Horsman had suffered an anaphylactic reaction to the contrast dye injected into him before the scan, but the switchboard operator repeatedly misunderstood the correct location - even though it would have been displayed on her screen.

The crash team which might have saved Mr Horsman's life was sent instead to a children's ward and only found Mr Horsman 17 minutes after the first call. They were able to resuscitate him, but he died the following day.

The inquest heard independent expert medical evidence that with prompt and appropriate care, Mr Horsman’s death would probably have been avoided.

The coroner said: "The levels, tone and effectiveness of these calls were far below what we would accept as a reasonable standard."

Following the conclusion of the inquest, Mr Horsman’s widow Jane said: "David went to the hospital for a routine scan and I stayed home because of covid restrictions still in place at Royal Bolton Hospital.

"We had no qualms about the procedure and spent the time preparing for a holiday we were about to take.

"I was horrified to receive the call that David had had a reaction to the CT scan procedure, and by the following day my world had been tipped upside down.

"After David was making a good recovery from the bowel cancer three years earlier, his death was completely unforeseen. To lose him when we were at the start of our retirement has been and continues to be devastating.

"To hear of the circumstances surrounding David’s death, the failings at Royal Bolton Hospital, have sickened me.

"I expected that David would be safe and would have trusted the hospital staff to take good care of him if something went wrong. Something did go wrong, but the hospital let David and his family down. I am appalled."

Negligence specialist Stephen Jones of Leigh Day solicitors, representing Jane Horsman, said: "Listening to the call recordings being played in court and hearing how things went so tragically and unnecessarily wrong was very upsetting.

"The process for calling the crash team was quite straightforward but was simply not handled properly.

"The crash team were reduced to roaming the hospital to try to locate the emergency, and when they finally came across David it proved to be too late to save him. David’s death should have been avoided.”

The inquest had heard Mr Horsman was being routinely scanned after being successfuly treated for bowel cancer and had never previously suffered a reaction to being injected with contrast dye.

Dr Francis Andrews, Medical Director at Bolton NHS Foundation Trust, said: "We fully accept the findings of the inquest and our commitment to the family and all who knew him is to make sure that we learn and do as much as we possibly can to prevent such a tragedy from happening again.

"We no longer commission private providers for radiology services; have continued to run simulation exercises related to identifying and managing anaphylaxis with our existing and new radiology staff; and all call handlers working in our switchboard service have taken part in extensive training before being able to continue in their roles.

"Nothing we can say or do will take away from such a devastating outcome for Mr Horsman’s family, and our sympathies remain with them.”