Old phone numbers and an incorrect email address meant Rowan Thompson's vital blood test results failed to reach Prestwich before their death, an inquest has heard. The 18-year-old, who identified as non-binary and used the pronoun 'them', died following a seizure on October 3, 2020.
Rowan was an inpatient on the Gardener Unit, run by Greater Manchester Mental Health NHS Foundation Trust (GMMH), on the site commonly known as Prestwich Hospital. Jurors have today (October 31) been sent out to deliberate after hearing evidence about Rowan's death at Rochdale Coroners Court over the past week.
After summing up the evidence this morning, coroner Joanne Kearsley told the jury it should consider whether attempts to communicate Rowan's blood test results the day before had contributed to their death. The results showed Rowan was suffering from 'severe hypokalemia' - a condition in which a person has too low a concentration of potassium in their blood, which is being considered by the jury as Rowan's possible cause of death.
The court had heard evidence from Dr Allamedine, clinical director at Northern Care Alliance, about the results which were produced on October 2, 2020, and indicated they had a potassium level of 2.3 millimoles per litre - a level which had been described by toxicologist Dr Stephen Morley as 'life-threatening'. Summing up Dr Allamedine's evidence this morning, Ms Kearsley recalled that the results were held in a laboratory at Salford Royal Hospital.
The test result was re-run at 1.37pm, and Dr Allamedine explained it should have been communicated verbally within two hours. The inquest heard that the results were first sent to GMMH electronically at 1.51pm - but the communication failed due to a 'software filter issue'.
Attempts were then made to reach the Gardener Unit by phone, but the number which Salford had recorded for it was out of date and the call did not connect. The court heard another attempt was made to call the unit using a phone number on its website, but again it was old and out of service.
Ms Kearsley recalled Dr Allamedine's evidence that a call was made to the switchboard at the Prestwich Site, where an email address was provided to try and send the results - but this was in fact for audio messages rather than text, so again the test results did not reach the Gardener Unit. The court heard that by 2.42pm, the test was removed from the list of results that still needed to be communicated from the lab at Salford, and at 4.58pm a final attempt to contact the Gardener Unit was made - with no handover given for staff to continue trying.
In his evidence, Dr Morley had suggested that Rowan would likely have survived if he was taken to hospital for low potassium at this point. Ms Kearsley recalled evidence from Dr Malik, the psychiatrist who worked with Rowan on the Gardener Unit.
Dr Malik only received the results of Rowan's blood test on October 5, two days after their death, and suggested he would have rushed them to A&E had he received them when he should have on October 2. Ms Kearsley told jurors that if they considered the issues of communication to have contributed to Rowan's death, they could consider whether to record 'neglect' in the case - meaning 'a gross failure to provide basic medical care'.
Jurors will also consider whether the admissions made by GMMH staff that observations had not been carried out on the morning of Rowan's death are 'matters of fact' in the case. However, Ms Kearsley told the jury there was no evidence to suggest this would have contributed to or caused Rowan's death.
Ms Kearsley told the jury: "Your duty as the jury is to find the facts and the conclusion from the evidence. This duty must transcend any feelings you may have of sympathy for any individual or organisation.
"You have to reach, at this stage, a unanimous conclusion." The jury previously heard that at the time of their death, Rowan - who had been diagnosed with autism and depression - was awaiting trial in connection with their mother's death.
Proceeding.
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