Inquest into death anaemic Carlisle patient, Michael Huggon

Michael Huggon, of Thirlwell Avenue, died in the Cumberland Infirmary in Carlisle during the early hours of February 7, 2024. 

A statement submitted to Cockermouth Coroner’s Court by his wife, Jean, said that Mr Huggon’s health had been declining since he firstly suffered a stroke in May 2023, and then in October 2023 was admitted to hospital again to treat pneumonia. 

Since then, he had suffered from shortness of breath and a number of associated symptoms. 

Mrs Huggon said that her husband was placed on a waiting list for a respiratory appointment, and would ‘likely be seen around mid-March, 2024’. 

She said that at 7,45 in the morning of February 6, 2024, she had taken him coffee and toast in bed. 

He said he hadn’t slept well, and would get up later. 

She said that he was ‘lethargic, slow, and didn’t want to eat anything’, and it took ‘a few minutes for his breathing to settle down’ after coming downstairs. 

Mrs Huggon rang the Carlisle Healthcare surgery at around 2pm to request a home visit, and received a call back after 6pm. 

She reported that the person who called said ‘Madam, do you know what time it is, it is after-hours and you will have to ring 111 after 6.30pm.’ 

Mrs Huggon said she then rang 111 and an automated voice said there would be a 40-minute wait. 

When connected, she was told an ambulance would be sent, but shortly after, Carlisle Healthcare On Call (CHOC) called to say that somebody would call back to see if an ambulance was needed in around 20 minutes. 

The call arrived to say that an out-of-hours doctor would be sent, Dr Patrick Gray. 

Dr Gray, addressing Assistant Coroner for Cumbria, Dr Nicholas Shaw, said that he arrived at the property at 8.47pm, and it was ‘immediately clear that Mr Huggon was clinically anaemic’. 

He said he tried three times to persuade Mr Huggon to go to hospital, and that was his advice. 

He said: “He did not wish to go, and was very clear on that decision. 

“He feared a night in a corridor, he’d had a bellyful of hospital.” 

Dr Gray left, having advised Mr Huggon to stop taking anticoagulants (which were prescribed for the recovery from his stroke), as they would worsen any internal bleeding, which could be causing his anaemia. 

He also said to call again if his symptoms deteriorate. 

Mrs Huggon said they went to bed at around 11.45pm, and Mr Huggon struggled to get up the stairs, and went into the bathroom.  

Mrs Huggon went downstairs to retrieve some medication for the morning, and found Mr Huggon unable to stand up in the bathroom. 

She said he then ‘suddenly slumped forward towards the wall’, and became unresponsive. 

She called 999, and paramedics rushed Mr Huggon to the Cumberland Infirmary, but doctors were unable to resuscitate him, and was pronounced dead at 1.47pm. 

Dr Shaw concluded that the cause of Mr Huggon’s death was death cardiac arrest due to hypovolemia (low blood volume), due to gastrointestinal bleeding. 

He said that that delay in treating Mr Huggon was ‘significantly causative’ to his death. 

Dr Shaw commented: “My concern here is the difficulty in getting access to medical care.  

“It sounds from the statement that she must have felt she was banging her head against a brick wall to try and get someone to come and see him. 

“The question I have in my mind is would Myke have accepted admission to hospital if he’d been seen earlier. 

“I would urge surgeries to consider their process.  

“The other thing that concerns me is the handover between the surgery and Cumbria Health at 6.30pm.  

“Might it not be better if someone actually spoke on the phone and said there’s a case we’re concerned about rather than having to go through 111, and cause a potentially lengthy delay, speaking to someone in a distant town with a computer algorithm and reaching the wrong conclusion?

“I’m going to write a short recommendation to consider that handover period.” 

Dr Shaw concluded that Mr Huggon died from natural causes.