A Crufts champion dog breeder died from sepsis after a missed diagnosis, and a wait of more than two hours on his second visit to hospital, an inquest has heard.
A coroner said Alan Hunter, 53, might still be alive today if he had been properly diagnosed and treated within the set standards, Grimsby Live reported. Alan, from East Halton, near Grimsby, died just a few weeks after his Great Dane, Phoebe, won the Best Bitch in Show award at Crufts in 2019.
At the two-day hearing at Cleethorpes Town Hall, Marianne Johnson, the assistant coroner for Lincolnshire, said the case highlighted the need for urgent action if sepsis is suspected. She was told that following the case, there had been significant improvements in the care of emergency patients, specifically those suspected of having sepsis, at the Diana, Princess of Wales Hospital in Grimsby. All are now seen within 15 minutes.
The inquest was told that as a dog breeder, Alan walked 10 miles daily around East Halton, where he and partner Carol Lawson ran their business , Pet Perfection. In May 2019, he became unwell with flu-like symptoms and an acutely painful and swollen knee.
On his first visit on May 27, he was discharged, following an X-ray, with a splint, crutches and painkillers. The nurse who saw him diagnosed a “locked knee” and said he should return if his condition worsened.
No sepsis screen was undertaken because he was not showing symptoms, although his heart rate was slightly raised, the inquest heard. But the next day, he was breathless and "grey-looking" and Carol again took him to hospital.
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She had to wheel him in on a chair because he was unable to put weight on his knee, but he had to wait two hours and 20 minutes to be seen by a nurse. And while he was being taken for tests, he suffered a cardiac arrest.
Doctors revived him and he was placed on life support. But his condition deteriorated and life support was withdrawn. He died on May 30, with Carol by his side.
In her conclusion, the coroner noted that no blood tests were taken on the initial visit to the hospital nor any advice sought from a doctor. “With hindsight, she [the nurse] should have done and accepted there was a missed opportunity,” she said.
Ms Johnson said of the second hospital visit: "Had he been seen sooner the outcome could have been different." Alan ought to have been seen by an orthopaedic doctor within an hour of arriving, the hearing was told.
Matron Natalie Till said on the night in question, which followed a Bank Holiday weekend, there were 49 patients on the ward and just four nurses. She said there is now a full establishment of 15 nurses through the day and evening in the hospital's emergency department.
Staff also undergo regular training in what to look out for in patients with potential sepsis. The coroner said: "I am satisfied major changes have been made and significant differences to the patient journey."
Ms Johnson expressed her condolences to Carol, Alan's partner of 30 years, and said she hoped the Trust had learned lessons. She added the inquest should have been heard sooner but the pandemic had created a backlog and an initial inquest date in September last year was postponed due to the death of Queen Elizabeth II.
After the hearing, Carol said she was continuing with the couple's pet grooming and dog breeding business and plans to enter her top dogs at Crufts next month. She said she is impressed by the new emergency facility at the hospital and welcomed the new systems in the emergency department. “It has come too late for Alan. It will be nice if it saves someone else’s life," she added.
She said she was just starting to build the business back up again, explaining: " It has taken years. I can’t manage everything on my own. We were partners in life and in business.
“I will never forget Alan. We lived together for 30 years. We didn’t have children, we had dogs. He will always be part of my lifer.”
Ian Sprakes, Carol's solicitor, said: “We are satisfied with the coroner’s conclusion which has identified the failings in the management of Alan Hunter. It is a tragedy of a man who has lost his life when he should not have.
"We are assured steps have been taken to improve the system. Time will tell.”
Peter Reading, the chief executive of Northern Lincolnshire and Goole NHS Foundation Trust, said: “We welcome the comments made by the coroner in her narrative verdict, which acknowledge the refined practices now in place around how patients are assessed and tested for sepsis.”
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