A 'SIGNIFICANT delay' in medical treatment at an A&E department contributed to the death of a man who was 'desperately ill', an inquest has found.

Gordon Hendley, 67, of Dalston, died in the Cumberland Infirmary on January 23, after suffering a rare allergic reaction to medication.

At an inquest held at Cockermouth Coroner’s Court on Wednesday, Coroner Dr Nicholas Shaw disagreed with a review published by the NHS Trust responsible for Mr Hendley’s care, which said there had been no delay in his treatment.

Dr Shaw also raised concerns over critically ill patients being admitted to hospital without a family member to speak up for them, during the coronavirus pandemic.

The inquest heard that Mr Hendley had been ill since the beginning of November and had spent nearly a month in The Cumberland Infirmary. He had a chest infection and a pulmonary embolism which had damaged his lung.

During that time, he lost a lot of weight and his wife Judith described him as 'gaunt'.

He had then been discharged from hospital with steroids. His wife said she didn’t recognise him because his face and mouth were so swollen.

Mr Hendley was referred back to the hospital by his GP on January 19 due to the swelling. His GP was concerned it was Stevens-Johnsons syndrome – a rare, 'very serious' reaction to medication which affects the skin and mucous membranes.

He was admitted to A&E but waited six hours to see a doctor and around 12 hours for a bed. There was no dermatologist available to see him.

Mr Hendley had been diagnosed with lymphoma in January 2020 but had received chemotherapy and was in remission.

Blood tests revealed Mr Hendley had low white blood cell counts and a CT scan showed he had pancreatitis.

The antibiotics required were not available but Dr Shaw said it would be 'quite impossible' for hospitals to stock every medication.

Mr Hendley was transferred to the Intensive Care Unit 24 hours after arriving at the hospital, but “despite their very best efforts”, he passed away on January 23.  

Dr Shaw said: “I feel there has been a significant delay in this case. Had he had bloods taken earlier in A&E... there’s been a significant time he has been deteriorating. Treatment could have been given which led to a happier outcome.”

The inquest heard evidence from Dr Rachel Liddicott, a consultant in emergency medicine, who was on-call when Mr Hendley was brought into The Cumberland Infirmary by ambulance on January 20.

Dr Shaw said to her: “He is a really desperately ill man. When he comes into the department at 10.30pm, he is seen by a triage nurse but is not seen by a doctor until 4.30am.

“He is extremely unwell. He remains in the department. There seems to be a lack of urgency in getting things sorted.”

Dr Shaw referred back to the case of Nicholas Dietzold, of Workington, who died in the A&E department of the Cumberland Infirmary in August 2020, after being left without care for more than five hours.

“I was told changes were being made in the emergency department. My feeling is he [Mr Hendley] is being allowed to slip through the radar.”

Dr Liddicott said intentional rounding – a process where patients are regularly checked – had been embedded into procedure. She said patients were checked on by nurses every hour and by an A&E consultant every four hours.

Dr Shaw said: “I do appreciate the pressure on A&E departments at the moment. It’s difficult to manage.”

The inquest also heard a statement from Judith Hendley, who said her husband’s care had been 'lacking' and he had been discharged from hospital with blood clots on his lungs before he was re-admitted.

She said she couldn’t go to the hospital with him due to Covid restrictions and each time she rang to find out how he was, she was 'fobbed off'.

Mrs Hendley said she was eventually told her husband was going to be taken to the ICU because he was so ill.

Coroner Dr Nicholas Shaw said he disagreed with a mortality and harm review published by the NHS Trust which said there had been no delay in Mr Hendley’s care and treatment.

“I’m afraid, I don’t accept the report. I don’t think it’s satisfactory. I’m sure A&E will be very busy. I find a six-hour delay difficult to justify.”

He raised concerns over the hospital’s communication with Mrs Hendley and said she was not taken into consideration and when she did ring the hospital, she didn’t get any answers.

“Judith couldn’t come with him to the hospital. This is something that has cropped up in other inquest cases where somebody is seriously ill and nobody is there to speak for them.

“I’m sure Gordon would fully accept emergency departments are busy places. He was severely ill. If Judith had been with him, she would have demanded action quicker.

“I know [in] cases I have heard, families aren’t able to be with patients at crucial times and aren’t able to speak up for them.”

Dr Shaw gave a narrative conclusion of a severe reaction to necessary medication. He said a significant delay to medical treatment contributed to his death.

The medical cause of death was Stevens-Johnsons syndrome, with contributing conditions of lymphoma, pulmonary embolism and lung abscess.

Dr Shaw said he would be writing to the chief executive of the NHS Trust with his findings.

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