Coroner hits out at patient's care
The death of a patient who was discharged from an under-staffed NHS hospital despite being unable to walk was contributed to by a string of serious failings in his care, a coroner has ruled.
In a narrative verdict, Leicester Coroner Catherine Mason said the death of John Moore-Robinson could have been prevented if staff at Stafford Hospital had provided him with "appropriate" treatment.
Mr Moore-Robinson, from Sileby, Leicestershire, collapsed and died in April 2006 within hours of being sent home in a wheelchair with an undiagnosed rupture to his spleen.
A second inquest into his death was told that staff at Stafford Hospital were informed by a paramedic that the 20-year-old's condition was potentially life-threatening.
But the telecoms engineer, who had been hurt in a cycling accident on Cannock Chase, was discharged later the same day after X-rays showed he had not suffered any bone fractures.
Recording her verdict after a three-day inquest at Leicester Town Hall, Mrs Mason identified six separate shortcomings which "more than minimally" contributed to the death.
Mrs Mason said: "The seriousness of Mr Moore-Robinson's condition was not fully appreciated and decisions in relation to his care were made on incomplete information as a result of poor communication, poor documentation, inadequate assessment, insufficient investigation and an oversight to consider medical notes that were available.
"If Mr Moore-Robinson had been managed in accordance with his needs, the clinical grounds necessitating his admission to hospital would have been apparent.
"The opportunity to provide appropriate care to treat his ruptured spleen and prevent critical collapse of the venous system would not have been lost and on the balance of probabilities the loss of his life could have been prevented."
Mrs Mason added that a "continuous sequence of shortcomings" had created a chain of events leading to an unsafe discharge of the accident victim - who was described by friends as confused and still vomiting.
Mr Moore-Robinson, whose friends had to use a wheelchair to take him to a waiting vehicle, later called an ambulance himself from his home but suffered a heart attack shortly after paramedics arrived.
Medics at Leicester Royal Infirmary attempted to revive him but he was pronounced dead at 2.35am on April 2, 2006.
An inquest held in 2007 also recorded a narrative verdict but Mr Moore-Robinson's parents, from Coalville, campaigned for a fresh hearing after new evidence came to light.
Concluding the second inquest, Mrs Mason found that Mr Moore-Robinson was not triaged properly, and that a nurse had failed to communicate "obvious" and relevant information to a doctor.
As a result of the failure, the patient was seen by a junior doctor more than an hour after his arrival at Stafford Hospital.
Routine procedures such as standard monitoring were also carried out inadequately, the new inquest heard.
A nurse told the new hearing that staff at Stafford felt "bullied" by a four-hour target for patients' length of stay in the accident and emergency department.
Commenting on the situation at the hospital in 2006, Mrs Mason added: "Although I was pleased to hear in evidence that the staffing levels have now much improved ... I find as of fact that on 1st April 2006 there was a failure to adequately staff the accident and emergency department which impacted on the adequacy of care."
Speaking after the hearing, relatives of Mr Moore-Robinson thanked the coroner for her "fearless" inquiry into the care provided by Stafford Hospital, which was the subject of a public inquiry ordered by the Government in 2010.
His sister, Kelly Hainsworth, told reporters: "The last eight years have not been about publicity, headlines or notoriety - it has been about finding the truth.
"It has been a long eight years but we have had to walk this path together to get justice and to make the NHS a safer place for everybody.
"We are satisfied with the facts that have been laid before the coroner and accept the findings."
Mr Moore-Robinson's father, Frank, said: "Stafford Hospital at the time was in melt-down.
"Many, many people have lost their lives, including our son John, and that we can never forgive them for. It's been a hard road but one we have had to take."