Three calls for help were made to a Royal Bolton Hospital call operator as a man lay dying suffering from an anaphylactic shock during a routine check up in a CT van in the grounds of the hospital.

David Horsman suffered from multiple organ failure after having an anaphylactic shock during a regular medical check-up at the Royal Bolton Hospital.

On Wednesday, day one of the inquest at Bolton Coroners’ Court, coroner John Pollard said the reaction was most likely due to ‘intravenous contrast’ – a dye used to highlight areas of the body being examined during a CT scan.

Anne Parker was working alone when she received an emergency call to the hospital’s switchboard just two minutes before the end of her shift.

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Despite radiographer Indogesit Okon asking for a crash team to be sent to the ‘CT van’ in a call at 15.58, Anne sent the team to area E5, on the other side of the hospital in the paediatric department.

At this point, Mr Horsman’s heart was still beating. It wasn’t until a few minutes later that it is now believed he suffered a cardiac arrest.

Mrs Parker did not seem to notice her mistake until the third emergency call from the van, five minutes later at 16.03, when Mr Okon again said he needed help at the ‘CT van’.

She then transferred the call to 999, as the incident was happening outside of the main hospital building. The crash team, however, were not told they had been sent to the wrong location.

In court, Coroner John Pollard asked: “You know you’ve got somebody collapsing in the CT van, you know you’ve got a crash team going to the wrong location, why didn’t you change it?”

Mrs Parker responded: “I don’t know, sorry, I can’t answer that.”

‘I’m out of my head here’

The mistake then led to Mrs Parker receiving a call with questions from site manager Claire Blaydon, at 16.05.

Mrs Parker told Blaydon that she was “out of my head here” and that she had been told the incident was happening in the paediatrics department by the caller.

In the call, which was read out to the court, Ms Blaydon then asks Parker if the man calling is ‘playing silly beggars’ to which Anne responds: ‘I don’t know, he’s a foreign gentleman’.

In court, Mrs Parker said she found it ‘difficult to understand’ what Mr Okon was saying.

Questioned by Ivor Collett, from InHealth, Mrs Parker was asked if these references meant that she was not taking the incident seriously.

She responded: “Of course I took him seriously.”

‘A man is literally dying waiting for a crash team to arrive’

The phone call ends with the site manager saying “OK lovely, alright darling, thanks for your help, bye love, bye.”

Coroner John Pollard said: “The family will have to forgive me for this, but a man is literally dying waiting for a crash team to arrive, and this is the sort of thing going on. It’s not very good is it?”

A call then comes through from the North West Ambulance Service to the main hospital’s switchboard, taking nearly two-and-a-half minutes to be answered, again by Mrs Parker – who says she doesn’t know if it was a false call and that the caller – Mr Okon – ‘doesn’t understand much English’.

In court, Mrs Parker said she now believes the reason for the confusion is she had put a call from E5 on hold at the time the emergency call came through, and that the room number may have still been displayed on her telephone.

Coroner Pollard said he thought it “didn’t really stand up to much scrutiny”, given that Mrs Parker had only brought up her theory in court.

‘Significant amount of confusion’

The crash team do not arrive at the van until 17 minutes after the first call was placed, at 16.15.

Dr Laura White, then a member of the hospital’s crash team, said there was a ‘significant amount of confusion’ as the team searched for a cardiac arrest patient in the hospital’s paediatrics department.

In court, Dr White said: “We’re currently on a ward where there’s supposed to be a cardiac arrest and there’s not one there, when you hear there’s one on the other side of the hospital that’s very worrying.”

Along with colleague Dr Jonathan Clarke, the team got up higher in the hospital to get a view of all the car parks, to see if they could see an incident.

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‘He was very blue’

The crash team finally arrived at the CT van, out of breath from their searches, after being flagged down by a member of staff in car park A, 17 minutes after the original call for help.

Dr Clarke said David looked ‘very blue’ when they arrived. The team then tried to use the defibrillator, but after attempting to apply a shock, decided to get another from an ambulance which had been hailed by another member of staff.

Dr White said that, despite the original defibrillator saying a shock had been delivered, in her clinical opinion, it hadn’t – with no telltale jolt seen as would be expected.

Resuscitation efforts, including 12 shocks and several shots of adrenaline, continued in the CT unit for 45 minutes, and there was evidence Mr Horsman’s heart was beating on its own again.

However, he then went back into cardiac arrest, and the team made the decision to transfer him to A&E with the help of a nearby ambulance crew.

Representing the family, Stephen Jones asked Dr Clarke for his thoughts on the equipment available in the van – which had no EpiPens available for staff to use, instead providing adrenaline ampoules which could be used – a situation the hospital Trust had said it was content with in emails in months before the incident.

Dr Clarke responded: “It’s only my personal opinion, but that set up would make me feel uncomfortable.”

‘We haven’t got a crystal ball’

Dr Sharmistha Saha, a consultant in anaesthesia and critical care medicine at the Royal Bolton, said she ‘fundamentally disagreed’ that Mr Horsman would have survived had delays not occurred.

While she accepted that the delay would have contributed to a ‘less positive outcome,’ she added: “We haven’t got a crystal ball, we can’t predict for sure what would or wouldn’t have happened.

“My take on this is if you have anaphylactic shock to the extent an individual is being pushed into a state of cardiac arrest your anaphylactic shock is so severe that your chances of being revived from that and your chances of successfully surviving that incident are slim.

“I would say there’s a significant chance the patient wouldn’t have survived that.”

‘The writing was on the wall’

Samer Nashef, a consultant cardiac surgeon, however, said he would ‘struggle to accept that the chances of survival would be less than 50 per cent’ had the delay not occurred.

However, he added that it was ‘very difficult’ to separate the impacts of the delays to Mr Horsman’s treatment with his ischemic heart disease caused by narrowed arteries.

Appearing over Teams, Mr Nashef added: “When you reach that point and you’ve had 86 minutes without circulation very few people will survive, whether their heart is in good nick or not.”

He added: “To put it bluntly, when he arrived at the emergency department and the ICU, the writing was on the wall and it’s not just the heart that caused the outcome.”

The inquest continues.

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