Press Release – 20th January 2023
The inquest into the death of David John Nash concluded today (20.01.23) following three days of evidence heard by Ms Abigail Combes, Assistant Coroner for South Yorkshire.
Ms Combes concluded that David Nash died at The General Infirmary at Leeds due to a brain-stem infarction (tissue death in the brain stem) arising from a cerebellar abscess (an infection in the brain) that in turn had arisen for undiagnosed mastoiditis (a serious bacterial infection in the mastoid bone behind the ear).
During the course of the inquest the Coroner heard evidence from staff and partners at David Nash’s GP practice, Burley Park Practice as well as from NHS Digital, Yorkshire Ambulance Service, NHS England and The Leeds Teaching Hospitals NHS Trust (the Trust). Additionally, the Coroner heard evidence from various expert witnesses including Dr Alastair Bint (a GP expert), Dr J D’Souza (also a GP) and Mr S Howarth (a Consultant Neurosurgeon).
The inquest opened with a moving pen portrait of David Nash read out by his mother Anne Nash in which he was described as a “wonderful son, brother and friend” with a strong sense of right and wrong and who always looked out for others.
During the evidence the following issues were highlighted:
- David had sought treatment during four separate appointments from Burley Park Practice (the Practice) between 14th October and 2nd November 2020 as his symptoms (including stiffness, headaches, jaw pain and a fever) developed. On each occasion he was spoken to by a different clinician (none of whom were his allocated GP), meaning the opportunity for continuity of care was limited.
- Due to the covid pandemic most consultations at Burley Park took place by telephone rather than in person. All four of David’s consultations took place over the phone. During the last consultation on 2nd November 2020 David was advised not to attend for his planned blood tests, due to having developed a fever, which the Advanced Nurse Practitioner conducting his appointment thought might indicate he had covid (this was despite a negative test a week previously). This was despite the fact that the Practice had a “hot room” where those with suspected covid symptoms could be seen.
- David and his partner also consulted NHS 111 on several occasions during 2nd November 2020 but he was directed down the ‘dental pain’ pathway by the NHS Digital algorithm due to the answers he gave. This meant he was not considered a priority, despite one call handler calling back to go over his answers again, because she was so concerned about him. NHS Digital have accepted that the system could be improved in this regard, and the algorithm has since been amended to make it more sensitive, with the aim of helping call handlers to accurately advise patients with serious conditions such as David’s.
- Eventually, following the fifth call that evening, and following a deterioration in David’s presentation, an ambulance was sent to take him to hospital.
- There were some delays in arranging a scan of David at St James’s Hospital and whilst awaiting a transfer from there to The General Infirmary at Leeds, during which time David’s condition deteriorated further. and he had become delirious, David fell from a medical trolley and struck his head. At this point he lost consciousness, which he never regained, though the fall did not in any way contribute to his subsequent death.
- Despite operations to relieve the pressure on David’s brain that was being caused by the cerebellar abscess, the abscess burst and David suffered extensive damage to the tissues of his brain. He died on 4th November 2020 after the withdrawal of life support with his parents’ consent. Since he never regained consciousness, they were unable to speak to him before he died.
- Whilst the experts were not critical of the first three contacts David had with the GP Practice, Drs Bint and D’Souza were agreed that during the 4th call on the morning of 2nd November 2020 there were ‘red flags’ in David’s presentation that should have led to him being told to see a doctor urgently.
- Dr Bint’s report includes the conclusions that the diagnosis reached by the Advanced Nurse Practitioner during that consultation was ‘not safe’, that ‘this was a patient that needed to be seen in person’ and that ‘had he been seen in person, it seems likely to me he would have been admitted to hospital’.
- Had David been seen face-to-face following the consultation and been referred to hospital, he would have been seen by a consultant approximately 10 hours sooner.
- Mr Howarth assisted the Coroner with the conclusion that if David had been seen by a consultant 10 hours sooner he would probably have survived.
The Coroner concluded, assisted by the expert evidence, that:
David died on 4 November 2020 at Leeds General Infirmary as a result of a brain-stem infarction, arising from a cerebellar abscess caused by mastoiditis. On 2 November 2020 there was a missed opportunity to direct David to seek face-to-face care during his GP appointment that morning. Had he been directed to seek face-to-face or urgent care by the GP Practice he would likely have undergone neurosurgery approximately 10 hours earlier than he actually did, which at that time it is more likely than not would have been successful.
Commenting after the inquest, David’s parents Andrew and Anne, said:
“As a family we have been devastated by David’s death. He was our wonderful son, brother, and friend. He had a strong sense of right and wrong, and always looked out for others. We in turn have spent two years seeking answers on his behalf, and to make sure that others don’t die as David did. We know that is what he would have wanted.
“We are relieved and grateful to Coroner Abigail Combes for concluding that, despite the pressures of the covid pandemic, David could, and should, have been seen face to face at Burley Park Medical Practice on the morning of 2 November 2020, and that this would probably have led to a hospital admission, and earlier care. We are both saddened and vindicated by the finding that the simple, and obviously necessary, step of seeing him in person would have saved his life.
“As we heard during the evidence, there were missed opportunities in terms of the 111 calls that were made on David’s behalf later that day, and there were mistakes made at the hospital, but David was already extremely unwell by the afternoon of 2 November, and it is unclear whether he could have been saved by different steps having been taken. We believe that the neurosurgeons who tried to save his life with emergency surgery were trying their best for him. Our main focus has always been on the fact that he should never have been allowed to deteriorate to that point in the first place.
“We are relieved that the organisations involved in David’s care have made changes to their policies and procedures following this inquest process: we hope that, by shining a light on his case as we have done, we will have helped prevent future deaths from occurring, and that we have done David justice.
“Finally, we want to take this opportunity to thank all those who have supported us in this difficult process and also wish to thank Iain Oliver from Ison Harrison Solicitors and our barrister, Rose Harvey-Sullivan from 7 Bedford Row Chambers. Their support, assistance and guidance has been invaluable to us.”
Iain Oliver, solicitor from Ison Harrison Limited, said:
“We are pleased that the Coroner conducted such a thorough investigation and inquest into David’s death. The scope of the inquest became wider than initially expected due to the possibility that the issues with NHS 111 or indeed at the hospital may have contributed to David’s passing and the family are grateful to the Coroner’s Service for permitting these avenues to be explored as well as grateful to NHS Digital and the Trust for their candour.
“This inquest has highlighted the limitations of telephone consultations with GPs and the need for patients to be seen in person wherever that is possible to ensure that proper assessment of conditions can be made. It has also highlighted the need for continuity of care within GP practices to ensure that the patient is considered holistically, particularly where there are repeated consultations over a short period of time.
“The GP practice, in a statement read by the Coroner today, has assured the Coroner, from the point of view of preventing future deaths, that their procedures have been reviewed and altered such that what occurred in David’s case is very unlikely ever to happen again.”
David’s family was represented by Iain Oliver of Ison Harrison Limited and Counsel Rose Harvey-Sullivan of 7 Bedford Row Chambers.