Terry Andrew Elvin, 59, of Highstone Road, Worsbrough Common, died in the Royal Hallamshire Hospital in Sheffield on September 7, 2018, three days after he was admitted to Barnsley Hospital suffering from headaches, dizziness and vomiting.
However, an inquest at Sheffield Medico-Legal Centre found a CT scan which showed an abnormality on his brain was not reported correctly.
Statements from a number of doctors from the acute medical unit at Barnsley, a paramedic, the deputy medical director of Yorkshire Ambulance Service and a consultant radiologist, led senior coroner David Urpeth to the conclusion that Mr Elvin’s death was contributed to by negligence.
It was heard that Terry’s son, also called Terry, said he recognised signs of a stroke when he was with his dad on September 4 and reported this when he was on the phone to a 999 call handler, but ‘couldn’t understand why it wasn’t registered’.
Paramedic Carl Goodwin said he had checked over Mr Elvin and did the FAST test as he received a query on the ambulance call screen which said stroke. But after taking Mr Elvin through the test and checking for signs of a stroke, found the 59-year-old to have ‘none of the symptoms consistent with a stroke’.
Dr Daniel Raw, consultant radiologist at Barnsley Hospital, said after examining the first of two CT scans there was a ‘significant abnormality’ which ‘should have been picked up on’ and that by the time he was transferred to the Royal Hallamshire Hospital it was too late to do anything.
Dr Raw added that there had been reviews in place to assess what had happened.
“We try and take steps from this to prevent it from happening again. This was a very difficult thing to pick up on, although it was there. It was an error.”
Mr Urpeth gave the medical cause of death of cerebellar stroke with acute hydrocephalus. He added there was a ‘failure to provide basic medical attention’.
“I have heard cold evidence that if the CT scan had been interpreted properly and appropriate treatment was given, then he would have survived, albeit with the risk of permanent severe disability,” said Mr Urpeth.
“He was let down by those that should have looked after him. This was a tragedy to those that loved him.”
Mr Urpeth added that he would also be writing a prevention of future deaths report on the matter.
Mr Elvin’s daughter, Joanne Elvin, who attended the inquest with her brother Terry, said: “It was hard to hear that if things had been different, he could have still been here and it was difficult to hear that it was medical neglect. We are glad this is over and done with but it’s hard to register. He died in 2018 so it has been a long time until the inquest.
“My dad, he was from Newcastle and known as the ‘Geordie’ to everyone.
“He had done so much community work from being a young man. If he went into town he would talk to everyone.
“He enjoyed being around people and having a laugh, he’d help anyone that needed it, loved music, appreciated a good meal and wouldn’t say no to a biscuit with a brew.
“His death has been a massive loss for us,” added Terry.
Dr Simon Enright, medical director at Barnsley Hospital NHS Foundation Trust, said: “The trust commissions some out of hours radiology services from an external supplier, Telemedicine Clinic, as is common practice across the NHS.
“We have taken the coroner’s findings extremely seriously.
“We have reviewed our own internal practices and will be seeking assurances from Telemedicine that they have fully taken on board the findings and recommendations from the coroner. We would like to offer our sincere condolences to Mr Elvin’s family at this difficult and distressing time.”