The widow of a retired engineer who suffered a fatal allergic reaction to a CT scan says she is “sickened” by hospital failings that a coroner has found contributed to his death.
Grandfather David Horsman, 65, from Westhoughton, went into cardiac arrest after having a reaction to a routine scan at a facility at the Royal Bolton Hospital.
An inquest into his death that concluded last week heard a communications breakdown between the radiographer carrying out the scan and the operator, causing the hospital crash team to reach him with a 17-minute delay.
READ MORE: Police issue statement saying a young man died in horror crash on Greater Manchester street – with two people arrested
They were able to revive him, but he died the next day. The inquest heard independent expert medical evidence that his death would likely have been avoided with prompt and appropriate care.
And after a three-day hearing that concluded last week, a coroner concluded his death was the result of a misadventure caused by neglect.
David visited a mobile CT scanner, owned and staffed by private company InHealth, located in a hospital parking lot on March 27, 2022, for a scan that was part of follow-up care after successful surgery for colon cancer.
He was injected with a contrast agent and underwent the scan, which took just over a minute. Shortly afterwards, however, he started feeling ill as he started coughing and his skin turned red.
Assistant coroner John Pollard said: ‘As he was clearly deteriorating, staff tried to call the radiologist on duty but there was no response.
“The staff in the van did not have the epinephrine auto-injectors and were not trained in how to withdraw and inject the ampoules stored in the vehicle.
“A call was made to the hospital via emergency number 2222 and although the radiographer did not follow the exact script, he did relay all relevant information to the operator.
“The operator did not clarify the exact location and in fact incorrectly introduced the idea that the patient was in the pediatric ward. This set off a chain of events that caused a 17-minute delay in the crash team’s presence. “
He was resuscitated but died the next day. A pathologist gave the cause of death as 1A) anaphylactic shock and 2) Ischemic heart disease. Mr Pollard concluded his death was a misadventure caused in part by neglect.
David’s wife Jane now says she and her family are ‘shocked’ at the way the hospital ‘failed’ her late husband. After the inquest, Jane said: “David went to hospital for a routine scan and I stayed at home due to the Covid restrictions still in place at the Royal Bolton Hospital. We had no trouble with the procedure and spent the time preparing for a vacation we were going to take.
“I was shocked when I got the call that David had had a reaction to the CT scan procedure, and the next day my world was turned upside down.
“After David recovered well from colon cancer three years earlier, his death was completely unforeseen. Losing him at the beginning of our retirement was and remains devastating.
“Hearing the circumstances surrounding David’s death and the failings at the Royal Bolton Hospital has made me sick. I expected David to be safe and trusted that the hospital staff would take good care of him if something went wrong. Something went wrong, but the hospital failed David and his family. I am shocked.
“I am grateful to the coroner for his careful consideration of what happened the day before David died. I am also grateful for the work and support of Stephen Jones of Leigh Day in my case, which has enabled me to achieve justice for what happened to David.”
Stephen Jones, of law firm Leigh Day, who represented the family, said: “Listening to the call recordings played in court and hearing how things went so tragically and needlessly wrong was deeply disturbing.
“The process of calling the crash team was quite simple, but was simply not handled properly. The crash team had to roam the hospital to locate the emergency, and when they finally encountered David, it proved too late to save him. David’s death should have been avoided.”
The Royal Bolton Hospital said significant changes have been made to their procedures following the tragedy. Dr. Francis Andrews, medical director of Bolton NHS Foundation Trust, which runs the hospital, said: “I would like to express my sincere condolences to Mr Horsman’s family as they continue to cope with such a tragic loss.
“We fully accept the findings of the inquest and our commitment to the family and everyone who knew him is to ensure we learn and do as much as we can to prevent such a tragedy from happening again.
“We no longer commission private providers for radiology services; have continued to conduct simulation exercises related to identifying and managing anaphylaxis with our existing and new radiology staff; and all call handlers who work at our switchboard have undergone extensive training before continuing in their roles.
“Nothing we can say or do can take away such a devastating outcome for Mr. Horsman’s family, and our condolences remain with them.”
An InHealth spokesperson said: “As a healthcare provider committed to delivering the very best care to our patients, we are deeply saddened that this unexpected death has occurred and extend our sincere condolences to Mr Horsman’s family.
“As with any incident, but particularly in this case, we have carried out a thorough review of our CT services and following Mr Horsman’s death we have implemented measures to address the specific circumstances to ensure we reduce the risk to an incident that does not happen anymore.
“As a learning organization with a culture of continuous development and understanding, we support all our colleagues in learning from incidents and have worked very closely with everyone involved in this case to ensure that the actions taken are embedded across our organization .”
Join our WhatsApp Top Stories and Breaking News group at by clicking on this link
Sign up to our Bolton newsletter to get the latest updates in your inbox