County Durham dad died after NHS 'mistakes and delays' which saw him wait hours in a hospital corridor
A Newton Aycliffe man's death following an overdose came after "a series of mistakes and delays" in A&E which "materially reduced his chances of survival", an inquest heard.
Kenneth Metcalfe, 63, died on October 14 2022. He had taken an overdose of prescription medication, including that which was used to treat his diabetes. Coroner Crispin Oliver said there had "clearly been a litany of mistakes and delays" in Kenneth's care, but his conclusion was that prompt treatment would not have prevented his death.
Kenneth had taken an overdose of his prescription medication on the morning of October 13 that year - the coroner agreed with the grandfather's family that rather than a deliberate suicide attempt, this had been a "cry for help" - especially as Kenneth had been concerned his broken mobile phone would mean he could not engage with drug and alcohol support services.
The coroner's conclusion was that Kenneth died "due to keto acidosis following an overdose of prescription medication". He found: "At some time on the morning of October 13 he had taken six days worth of his prescription medication."
Kenneth's family remain "heartbroken" and "outraged" by what happened, and told ChronicleLive after the inquest how they "hope no-one else has to go through this". Daughter Donna spoke of how the family had been hugely distressed by the scene they found on October 14 when their father rapidly deteriorated.
Donna paid tribute to her father. She said: "He was lovely. He brought us up by himself and did three jobs. He was a caretaker at a college. He started to struggle with depression. He was just struggling." Speaking after the inquest, Donna said: "They should have taken bloods from minute one. What we saw, no-one should have to see."
Kenneth was found, seriously unwell, having taken an overdose after lunchtime on October 13, when a member of his family went to check on him. He had been struggling with depression and alcohol dependence. On discovering he had taken an overdose, an ambulance was called.
At the inquest, evidence from the ambulance crews to care for Kenneth was heard. The first ambulance crew were assigned the job at 3.36pm. They arrived at Kenneth's home in Newton Aycliffe at 3.39pm and recorded their first observations at 3.46pm.
They left to take him to hospital at 4.34pm and arrived at hospital at the University Hospital of North Durham's A&E unit at 5.15pm. He was not "handed-over" by paramedics to the care of A&E staff until after 9pm - meaning he spent more than three hours in a hospital corridor waiting for a bed. Though blood tests were taken, they were "phoned in" to the department at 11.17pm and taken by Foundation Year 2 doctor, the court heard.
But these test results were not handed over to the clinicians looking after him in the A&E unit's monitoring area - and weren't acted on. Nor could they be viewed in the A&E's then new electronic patient record system. By 11.30pm it was identified that Kenneth needed intravenous fluids, he did not get these until 5.30am the next day.
Expert witness Dr Neil Langford told Crook Coroner's Court how he felt the care Kenneth received had been below-par. Summarising his evidence, Coroner Oliver said: "You are quite clear that initial investigations were sub-optimal and reduced Mr Metcalfe's chances of survival. Likewise, ongoing management was substandard and reduced Mr Metcalfe's chances of survival."
However, Dr Langford found that on the balance of probabilities the death was not preventable. Also, asked if Kenneth receiving treatment quicker - if "ten to 15 minutes had been shaved off" the time taken to get him to hospital - would have saved his life, Dr Langford said he did not believe so.
While Dr Langford's evidence found that paramedics should have considered giving Kenneth activated charcoal to treat the overdose, he said: "It should have been considered but the fact it wasn't was not, I don't think, unreasonable. We can say with hindsight it should have been given, but I'm not critical of the paramedic team for not giving him it."
Both the County Durham and Darlington NHS Trust and the North East Ambulance Service have apologised to Kenneth's family. The hospital trust - which runs both University Hospital of North Durham and Darlington Memorial Hospital - admitted a series of failings.
In a letter to the family, NEAS chief executive Helen Ray apologised explained that an internal review had concluded how the initial crew to attend had not recognised how poorly Kenneth was, spent too long on the scene, and should have "pre-alerted" him to the nearest A&E rather than following the "deflection" which was in place at Darlington Memorial.
Mrs Ray wrote that NEAS had "very regrettably" identified serious errors in Kenneth's care. She added: "I want to apologise wholeheartedly to Miss Metcalfe for the inevitable upset that this will cause to her and her family. The whole experience of care has been substandard, and Mr Metcalfe deserved better from us."
That letter also discussed how: "We have not met the required standard of care for Mr Metcalfe when he was extremely poorly, and we have let him and his family down."
A spokesperson for County Durham and Darlington NHS Foundation Trust said: "We would like to express our deepest condolences to the family and loved ones of Kenneth. The Trust conducted a full and thorough internal investigation and identified areas where improvements could be made, and as a result, a series of actions have been put in place to ensure we provide the safest and highest quality care to our patients.
"These actions include enhanced learning sessions for our staff, the introduction of new Standard Operating Procedures (SOPs), and an audit programme to monitor and ensure ongoing improvements. We are committed to learning and continuing to make positive changes to improve patient safety and care."