Dog walker's death was preventable, coroner says

Mark Richard Hinton, 52, went to the Princess Royal Hospital in Telford on October 8 with swelling and pain to his calf after being struck by his dog.

An inquest into his death at Shirehall on Thursday heard how proper notes were not made or not made at all, and there were missed opportunities before he was discharged from hospital.

Coroner John Ellery said on October 9 Mr Hinton, who was born in Shifnal but lived in Windsor Avenue, Wolverhampton, collapsed at his girlfriend’s home and, after being taken to hospital, he died shortly after 2am in October 10.

Mr Ellery said a number of errors had been made and recorded a conclusion of a preventable natural cause.

Dr Cerys Burrows, who carried out the post mortem, said Mr Hinton’s cause of death was pulmonary embolism, caused by deep vein thrombosis and contributed to by a bleeding ulcer. Mr Ellery read out a serious incident report put together by the hospital, which found that if Mr Hinton had been given effective treatment in time, his death was probably avoidable.

Three nurses and two doctors involved in Mr Hinton’s care while in hospital give evidence and were questioned by Mr Ellery and Mr Hinton’s family.

The inquest heard Mr Hinton had gone to hospital after being advised to when calling the NHS 111 number. The call handler told him he might be suffering from a blood clot but the inquest found this wasn’t mentioned in his notes.

Nurse Tina Smart, who treated Mr Hinton, had said that a D-Dimer test might be required. The test can help to diagnose deep vein thrombosis. It was ordered, but the inquest could not discover who had ordered the test because of the way the IT system worked.

When the results had came back Mr Hinton had already been discharged from hospital.

Failures

Dr Jesse Niemadim, who prescribed Mr Hinton with pain killers, said he was not aware of a possible clot and did not have all the information about the patient because it had not been made in the notes. When he saw the patient later in the evening on October 8 he did not suspect a clot as the swelling had reduced. He was also unaware a D-Dimer test had been asked for.

He said it was of his view that Mr Hinton was suffering from an infection.

Mr Ellery said: “Whoever requested the D-Dimer was right to do so, but when the results came back it was too late. The notes made are poor, and in places not at all. There is no record of who ordered the D-Dimer.”

The doctor also said on the day in question it was an abnormal day, with a big patient load.

Dr Lambadin added: “I know it doesn’t mean much now, it is a very difficult time and a sad thing has happened but I am really sorry about it.

“It is sad the system is the way it is, there has been so many gaps in all of this.”

Mr Ellery gave his conclusion and said he would be writing to the hospital trust to point out areas of concern included not recording blood clot concerns, recording who can call for tests and other areas of the system.

He said: “The trust investigation found that the death was avoidable if the doctor knew about the D-Dimer result.

“If he would have known it was an elevated result he would have admitted Mark for treatment.

“It is clear there were serious individual and system failures.

“I have identified these failings so that what happened to Mark should not happen to any else.

“I am going to review the evidence and I will be writing to the trust to highlight my concerns that have arisen from the inquest.”