Inquest hears of NHS failings

This week an inquest at Lincoln Cathedral Centre heard how Mr Beresford, 44, of Forster Street, Gainsborough, died on 11th August 2010 of a massive heart attack.

Just days before, doctors had failed to recognise the oncoming symptoms, which could have prevented his death.

Lincs Coroner Stuart Fisher said there were four ‘missed opportunities’ to get him emergency treatment.

But despite telling health professionals that heart problems ran in his family, he was told he had a chest infection and given antibiotics.

Eleven days later Mr Beresford, a lorry driver, collapsed in a toilet cubicle at a building site in Navenby. Resuscitation was unsuccessful and he was pronounced dead at Lincoln County Hospital.

Originally from Lincoln, he had lived in Gainsborough for five years with partner Tina Coupland and their daughter Isobella, now four.

The inquest heard how on the morning of Saturday 31st July 2010 Ms Coupland had got him to call the NHS Direct helpline.

She wept in court as a recording of the telephone call was played, hearing Mr Beresford describe shooting pains in his chest and arms.

He had also complained of being breathless when exerting himself just slightly, and having a bit of a cough - which he put down to being a smoker.

An expert GP and a cardiologist both gave evidence at the inquest, saying Mr Beresford’s symptoms were clearly cardiac related, and would have warranted an immediate 999 call.

But that call was never made.

Even NHS Direct’s clinical director Tricia Hamilton agreed Mr Beresford’s symptoms were consistent with a cardiac event. She told the inquest that at the earliest stage of Mr Beresford’s call, a health adviser could have - and should have - called an ambulance.

“I deeply regret the actions and inactions of my staff,” she said.

“This is a very serious case.”

When Mr Fisher added: “A very serious failure?” she replied “Yes.”

Ms Hamilton also said the health adviser had failed to log Mr Beresford’s initial complaint as chest pain.

This error had trickled into the assessments of three other health professionals, causing a misdiagnosis.

The health adviser transferred Mr Beresford’s call to a nurse adviser - Beatrice Makonyola.

She took more information and advised that his symptoms were not associated with a heart attack, but a chest infection.

She told the inquest: “If I knew his pain was caused by a cardiac problem I would have referred him to the ambulance service.”

“I’m very sorry that I and other professionals who spoke to Mr Beresford failed to recognise that.”

Dr Richard Smith - an out of hours GP based at Lincoln County Hospital - next spoke to Mr Beresford.

He told the doctor he was worried because his mother had died after an angina attack aged 50, and his father had a heart attack at 65.

Dr Smith booked an immediate appointment for him to see Dr Kevin Lee at John Coupland Hospital.

But he told the inquest: “I wish I had delved more into the chest pain.”

Dr Lee spent ten minutes assessing Mr Beresford’s condition, but failed to make vital checks like blood pressure and pulse. He diagnosed a chest infection and prescribed antibiotics.

Internal investigations since Mr Beresford’s death, by both NHS Direct and the NHS out-of-hours service in Lincolnshire, have prompted changes in communication procedure and greater awareness of chest pain guidelines.

Nurse Makonyola and the health adviser were suspended during the investigations, but after further training it was deemed they could return to work.

Speaking after the verdict, Mr Beresford’s family paid tribute to a ‘devoted family man’.

Brother Marlon Beresford, 42, said: “We have lost someone we dearly loved. Tina has lost her partner and Isobella has lost her daddy who she adored.”

“Their plans for the future have been dashed and burned to ashes.”

Recording a narrative verdict, the coroner said: “I am satisfied NHS Direct have taken this matter very seriously.”

“There is a clear recognition by NHS Direct and Lincolnshire Health Trust that there have been serious failings on both of their parts.”