Locum’s incorrect diagnosis and catalogue of other failings ultimately contributed to businessman’s ‘preventable’ death
A medic who wrongly diagnosed Denis Doran with a hernia before he suffered a fatal heart attack was "not sufficiently qualified" to work as a consultant in the UK, the coroner found.
Patrick McGurgan told the devastated family of Mr Doran (57) that the Lurgan businessman would probably still be alive if not for the individual failings of a locum consultant at Craigavon Area Hospital in August 2016.
He said Dr Mohammod Asaduzzeman "lacked the robust training" and was therefore "not sufficiently qualified" to be working as an acute medical locum consultant.
Earlier this week the Bangladeshi-born doctor admitted he failed to recognise textbook cardiac symptoms which Mr Doran presented with to A&E.
The married father-of-two, who was known as Denny, died almost two months later on November 19, 2016.
The coroner said that Dr Asaduzzeman's incorrect diagnosis meant there was no follow-up investigations which ultimately contributed to his "preventable" death. However, he also found that a catalogue of "heart-wrenching" revelations showed "systemic" failings within the Southern Health and Social Care Trust.
Mr McGurgan expressed alarm that less stringent rules around the appointment of locum consultants allowed Dr Asad (as he was referred to in court) to work in that capacity despite not having "satisfactory experience".
The coroner previously branded the ability of medics who trained outside the UK to "circumvent" the system as appalling.
He expressed concern that there was no formal interview of Dr Asad who simply forwarded his CV to the Trust. It was also accepted that no formal induction process was given to Dr Asad, who told the inquest he was "not aware" that a Rapid Access Chest Pain Clinic existed. "He simply attended his shift and commenced his ward round," Mr McGurgan said. He said there was no scrutiny of the doctor's competencies.
Mr McGurgan also found that waiting times - which still exceed the two week target - for access to a Rapid Access Chest Pain Clinic represent a potential risk to public safety and resulted in a "missed opportunity" in this particular case.
It was almost a month after being wrongly diagnosed that Mr Doran was eventually referred to the clinic by his GP, but he died before the appointment.
Mr McGurgan said an earlier referral and shorter waiting time would have resulted in a "different outcome" for the patient.
The coroner stressed his belief that Dr Asad is "genuinely contrite" about his error.