Coroner Hears How Doctors Repeatedly Failed To Spot Fatal Signs

Inquest Records A Narrative Verdict After Staffordshire Man Is Sent Home To Die On Christmas Day

A Coroner has today (Thursday 6 May 2010) recorded a narrative verdict into the death of a Staffordshire father, who died from blood poisoning on Christmas Day 2007, as a result of an undiagnosed illness.

Malcolm Drake (23) from Blurton in Stoke on Trent developed an abscess, following a perforation in his bowel, as a result of undiagnosed Crohn's Disease but, for six weeks, doctors all failed to spot the symptoms and instead suggested he had a groin strain.

Now medical negligence solicitor, Lindsay Gibb, from law firm Irwin Mitchell, who is representing Mr Drake' fiancée, is calling for lessons to be learned to ensure future tragedies are avoided.

The inquest heard that Mr Drake, who worked in traffic management for distribution company, Blue Arrow, first became unwell in early November 2007. He began suffering from diarrhoea and sickness together with severe stomach pains. Initially he was told it was a simple stomach bug but, in the following weeks, the symptoms became worse. He lost his appetite, developed unbearable pain in his abdomen and a swelling in his leg.  He struggled to walk and was bent double in pain.

He was seen by his own GP, A&E clinicians and an out of hours locum GP on a total five occasions over a period of six weeks but each time was told he was suffering from a groin strain or muscular disorder.  When he returned to Stoke based University Hospital just three days before his death he was seen by a locum GP who had been allowed to work in A&E whilst the out of hours GP clinic premises, where he should have been based, were finalised. It was his first day working at the hospital.

Recalling events on 22nd December, his partner, Sophie Lindop, recalls: "Malcolm was in a terrible state. I had never seen him like this before and he was shouting out in pain. He had collapsed whilst at home alone and had to shuffle across the floor to call an ambulance. On the way to A&E he had to have gas and air as he was in so much pain. I couldn't believe it when he was seen by an out of hours locum GP who repeated that it was probably just muscle strain and told Malcolm to get dressed and go home.

"I had to get him a wheelchair to leave the hospital as he was too ill to even walk.  I somehow managed to get him back home and struggled to get him out of the car. Once in the house he collapsed in the lounge."

By Christmas Eve, Malcolm was unable to move from the sofa and was being constantly sick. A further phone call was made to the couple’s GP surgery but a doctor did not visit Malcolm at home.

On Christmas Day, at Malcolm's insistence, Sophie took their 5 month old baby son, Zak, to her mother's for Christmas Dinner. "I really didn’t want to go, but Malcolm really wanted Zak to spend time with his grandparents. The whole time I was there I felt uneasy and I rang Malcolm repeatedly to make sure he was ok. When I phoned at 1.45pm I got no answer and I just knew something was wrong."

Sophie returned home, accompanied by her father, to find Malcolm unresponsive. "I walked into the house and the Christmas tree lights and TV were still on.  I found Malcolm on the sofa and I knew instantly that he was dead.  I called 999 but my Dad had to take over as I was unable to speak."

Sophie's father desperately attempted to resuscitate Malcolm but when paramedics arrived they confirmed that he was dead.

A post mortem confirmed that Malcolm had died as a result of sepsis (blood poisoning) brought about by a peri-ileal abscess (bowel abscess) which had developed as a result of undiagnosed Crohn's Disease.

Lindsay Gibb, a medical negligence expert with Irwin Mitchell Solicitors, is representing Malcolm's partner, Miss Lindop. She explained: "The inquest has answered a number of important questions regarding Malcolm’s tragic and untimely death.

"I am extremely concerned that despite the fact Malcolm repeatedly sought help from a number of doctors no-one properly assessed his symptoms, re-considered the diagnosis or referred him for urgent investigation. There were several opportunities to intervene but sadly these were missed and he suffered greatly in his final few weeks. 

"Malcolm's family are particularly angry that, just three days before his death, despite attending hospital for a second time and being taken by emergency ambulance, he was treated as a minor injuries case and allowed to be seen by a locum GP.

"The inquest heard that, had Malcolm instead been seen by any member of the A&E team, he would have been referred to a senior doctor for review and, if proper investigations had been carried out, there would still have been an opportunity to treat his condition and spare his life. 

"Following Malcolm's death, a Serious Untoward Incident Investigation was carried out by University Hospital of North Staffordshire NHS Trust which recommended a review of the practice of locum GPs working within A&E, particularly their supervision, training and management.

"Whilst we hope that this review means the Trust acknowledges lessons must be learned, sadly it comes too late for Malcolm and his family. As a result of the failings identified both at today’s inquest and as a result of separate independent investigations, I can confirm that the family intend to launch a civil action to gain justice for Malcolm, his fiancé and son."