The family of a high-risk patient who died from septic shock at Bradford Royal Infirmary are pursuing a civil claim against the hospital for compensation after a Coroner said it was “abundantly clear” his special needs had not been met during his treatment.
Stephen Smith, 51, of Orchard Grove, Greengates, who had had a kidney and liver transplant, had his sickness, diarrhoea and groin pain diagnosed in A&E as gastroenteritis – it was another 14 hours before doctors put him on antibiotics suspecting an infection.
Even before arriving at hospital, Mr Smith had probably already been developing septic shock from a killer streptococcal bug which he could have picked up from a minor skin wound.
Now Assistant Bradford Coroner Dr Dominic Bell has urged Bradford Royal Infirmary chiefs to introduce a system to alert staff to high-risk patients at an inquest into Mr Smith’s death.
He has asked Bradford Teaching Hospital Foundation Trust to look at bringing in a ‘Special Patient Status’ category for patients like Mr Smith, who are particularly vulnerable to infection and therefore at greater risk.
Recording a narrative verdict yesterday into the warehouse worker’s death, Dr Bell said there had been “an unfortunate series of individual shortfalls, incompetencies and performances” during Mr Smith’s care.
He noted that Mr Smith had “never been flagged up” as a vulnerable patient and other concerns raised during the inquest were gaps in doctor’s notes, record-keeping and hand-overs.
There were delays which included not referring Mr Smith earlier for critical care and the hospital not informing his family sooner that he was deteriorating before he died on December 5, 2012.
Dr Bell said there had been errors of judgement rather than a lack of care and said he wanted to hear back from the Trust in four weeks about his suggestion of Special Patient Status.
Dr Bell did say the Trust had acknowledged its shortfalls early on and had carried out a robust investigation implementing remedial measures – but he felt more was still needed.
He acknowledged the Trust was committed to making improvements.
But now Mr Smith’s family solicitor, Hayley Cawthorne, said she was pursuing a civil claim for compensation and added: “We are in the process of obtaining independent expert evidence.”
Mr Smith’s widow, Anona, said the family hoped some good could come from his death and that new guidelines on sepsis for hospitals, which have already been implemented by the Bradford Trust, would now be implemented nationwide.
“I think our girls would want to know some good has come from their daddy’s death and other people might be helped in the future,” she said.
Dr Bell concluded: “It is likely that Stephen would not have died at the precise time he did if he had received antibiotic therapy and provision of intensive care support commensurate with his condition, care needs and healthcare standards at the time of this unfortunate episode.”
After the hearing a Bradford Teaching Hospitals NHS Foundation Trust spokesman said: “We would like to assure Stephen’s family that we are addressing all necessary actions and acknowledge the conclusion made today by the Coroner.”