Death of David Horsman, aged 65 at Royal Bolton Hospital was due to misadventure contributed to by neglect concludes coroner

Concluding a three-day inquest at Bolton Coroners’ Court on Friday 24 May 2024, Coroner John Pollard said David’s death was significantly contributed to by a breakdown in communication between the radiographer conducting a scan on David and the switchboard operator which led to a critical delay in his receiving appropriate treatment.  

  

The radiographer made an emergency call to the switchboard when David suffered an anaphylactic reaction to the contrast dye with which he had been injected prior to the scan being carried out. The scan was taking place as a routine check because David was a bowel cancer survivor. He had never previously experienced a reaction during his annual CT scans.  

  

The switchboard operator who took the radiographer’s call wrongly sent the crash team to a children’s ward at Royal Bolton Hospital instead of to the mobile scanning van where the scan had taken place.

Two more calls were made to the call handler by the radiographer, but the call handler continued to misunderstand the correct location of the cardiac arrest call, even though this would have been displayed on her screen. As a result, the crash team did not arrive to help David until 17 minutes after the first call. They were able to resuscitate David, but he died the following day.  

  

The inquest heard independent expert medical evidence that with prompt and appropriate care, David’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." 

 

In the coroner’s view, had the correct location been communicated properly to the crash team, they would have been able to arrive to help David before his cardiac arrest, and on the balance of probabilities, he would have survived.  

  

Following the conclusion of the inquest, David’s widow Jane Horsman 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.  

  

“I am grateful to the coroner for his careful consideration of what happened on the day before David died. 

 

“I am also grateful for Leigh Day’s Stephen Jones’ work and support on my case in allowing me to achieve justice for what happened to David”. 

  

Jane Horsman was represented at the inquest by Leigh Day clinical negligence partner Stephen Jones.  

  

Stephen Jones 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.”