Coroner slates Carlisle Hospital Trust after patient death

Assistant Coroner for Cumbria, Mr Robert Cohen made the remarks at the third hearing of the inquest of William Henderson, 53, a  window cleaner from Gretna.   

The patient died in the Cumberland Infirmary on March 27, 2023, after suffering two bleeds on his brain as a consequence of treatment he underwent to dissolve the clot that had caused an ischaemic stroke.

The hearing, which took place on October 14, was the third in the inquest into Mr Henderson’s death.

Assistant Coroner for Cumbria, Mr Robert Cohen, who had adjourned the two previous hearings, explained why this had happened.

He said: "The major reason is repeated problems with evidence presented to the court for and on behalf of the Cumberland Infirmary."

He said there was 'missing information', and witness statements that were 'misleading'.

Mr Cohen pointed out that he did not believe that these errors were intentional, but showed 'lackadaisicalness’ in the way the evidence was prepared.

He said the Trust's approach had been 'very unhelpful'.

Mr Henderson, known as 'Stan' to his family and friends, was admitted to hospital on March 24, 2023, after his partner of 20 years, Gillian Rosado, said he woke up at 8.30am and 'realised he couldn’t talk'.

According to Dr Thi Thi Oo, who treated Mr Henderson upon admission to the Cumberland Infirmary, a CT scan showed that Mr Henderson had suffered an ischaemic stroke (blood vessel blockage), with no bleed on the brain.

Although the exact time of Mr Henderson’s stroke was unclear, Dr Oo considered  him a 'good candidate' for thrombolysis, a procedure that is designed to dissolve existing blood clots, at 12.49pm.

A previous hearing had heard that guidelines state that a thrombolysis carried out more than four hours after a stroke carries too great a risk to be performed.

Dr. Shuja Punekar, a stroke consultant who cared for Mr Henderson from the morning of March 25, was called to Cockermouth Coroner's Court to give evidence in the case.

Answering Mr Cohen's questions, he said that Mr Henderson's condition began to deteriorate around two hours after the thrombolysis, and a second CT scan performed at that point showed two bleeds on his brain.

He said this was a known complication of thrombolysis.

Dr Punekar said that his blood pressure was also 'very high' at  205/188, and he was placed on intravenous ramipril, an anti-hypertensive drug.

He said that Mr Henderson’s blood pressure had stabilised overnight, and so the following morning, March 25, was prescribed ramipril to be taken orally.

Dr Punekar said the reason for this is that oral administration is less distressing for the patient, and less labour-intensive for nursing staff, and that once a patient’s blood pressure had stabilised, oral ramipril was an effective anti-hypertensive drug.

Mr Henderson’s family claimed that he was unable to swallow, and therefore oral administration would have been ineffective.

Dr Punekar said that a 'swallow assessment' had been carried out by a nurse and he was deemed able to swallow, despite Ms Rosado's assertion that he had choked when trying to swallow.

Two previous witness statements submitted by Dr Punekar said that the ramipril had been prescribed to be administered via a naso-gastric tube, rather than orally.

When questioned about this by Mr Cohen, he apologised for this 'mistake'.

Throughout March 25, Mr Henderson's condition and blood pressure continued to deteriorate, and upon seeing him at around 9.30am on March 26, placed him back onto intravenous hypertensive drugs and to be fed by a nasogastric tube.

His condition did not improve, and Mr Henderson died on March 27 at 8.45pm.

According to Dr Punekar, he had been assessed by an on-call junior doctor at around 8pm on Sunday 25, and prescribed two more ramipril, the last being administered at around 8am on March 26, just an hour and a half before Dr Punekar deemed that he required a nasogastric tube for fluids and nutrition.

Mr Cohen said: "In my view, the nurses are honestly recording that they considered that they had administered him doses of ramipril.

"However, the fact that somebody has put a medication in a person's mouth and offered them some, doesn't mean that person had effectively received the medication.

"I suspect that certainly by the morning of Sunday 26, any medication that somebody had attempted to give Stan orally was not actually doing anything

Mr Cohen also called it 'depressingly familiar' that the drug chart showing who would have prescribed the oral ramipril at 8pm on March 25 was an 'indecipherable scribble', rendering him powerless to identify the individual to question them.

Mr Cohen concluded the medical cause of Mr Henderson's death was bleeding on the brain, caused by thrombolysis, carried out because of a stroke.

Addressing Mr Smart, representing North Cumbria Integrated Care NHS Foundation Trust, Mr Cohen said: "You've heard me make two particular criticisms of the Trust.

"One of which relates to the participation in the inquest and the quality of witness statement.

"The other is the quality of drug records.

"I know you will relay to your client how seriously these matters are taken, and how important it is that in future, we use the inquest process to allay family concerns, not to exacerbate them."

Finally, Mr Cohen addressed Mr Henderson's family members in court.

He said: "You have participated in this hearing in a really unusual way.

"You have absolutely identified proper concerns, and you've raised them in an invariably courteous and reasonable fashion, and you have properly sought answers, necessary for you but also for Stan, and I pay tribute to you for doing that.

"Stan was a loving father, stepfather, and grandfather who is terribly missed by his granddaughter.

"He was a huge and vital personality to his family and friends who loved him."

A spokesman for North Cumberland Integrated Care said: "We would like to pass on our sincere condolences to  Mr Henderson's family at this very distressing time.  

"We note the coroner comments.  

"These will be shared within our organisation and we will give careful consideration to how we respond."