World champ pool player dies after Devon hospital 'neglect'

The untimely death of world champion pool player Jason 'Tornado' Twist from a fatal blood clot following an admission to hospital with back pain and numbness is said to have been caused by 'neglect' and a failure to provide 'basic medical care'. The father-of-five passed away at the Royal Devon and Exeter Hospital on May 14, 2023, a week after his admission.

An inquest at Exeter Coroner's Court this week concluded the inadequate care the 55-year-old received played a direct role in his death. His family heard that changes have since been implemented at the hospital to prevent any similar further tragedies.

Following the outcome of the inquest, they are now considering taking legal action against the RD&E after their trust in health professionals was 'gravely betrayed'.

Before Jason's death, he was living in Ilfracombe at his family-owned care home, a former hotel, where he worked as a manager in between playing pool, and was described as being in good health.

In a statement read out during the inquest, his partner Alana, who has since changed her surname to Twist because they had been planning to get married, told how they had been together for 15 years and had a daughter.

She said: "We were soul mates. He was and will always remain my absolute world. He was the most loving partner and father, and the kindest and most humble man you could ever meet with an infectious sense of humour."

Jason was born in Sutton Coldfield, Birmingham, and started playing pool from the age of 12 and soon achieved his dream of becoming a professional pool player. By the age of 21, he had become an international player representing England. As well as playing for the Devon county side, he also had his own team in Ilfracombe.

Praising his achievements, Alana said: "In the world of pool, Jason was one of greatest players winning numerous titles over his career and continued to do so right up until his hospital admission. Jason was well-known nationally and internationally due to his career and he was certainly a major party of our community in Ilfracombe, especially supporting the local pool leagues who he was vice-chairman of.

"There was never a bad word said about Jason. He was an incredible person who was extremely supportive to all those he met. He was kind and a pleasure to be around."

She said his health had been 'pretty good' but he suffered with his lower back which he put down to his cueing stance when playing pool. On May 3, 2023, she recalled he complained of pain in his lower back running down his leg the day after he had been moving some heavy rubbish bags, and thought it could be sciatica.

A couple of days later he was experiencing numbness in his groin and saddle area and believed it was a trapped nerve. However, on May 6, he was taken by ambulance to North Devon District Hospital after the numbness became worse.

He was transferred to the RD&E for an MRI scan which could not find a cause for his symptoms. Following further testing, the working diagnosis was inflammation of the lower part of the spinal cord.

Alana recalled she raised concerns about his health and care during his stay, such as his urine monitoring and not being on medication.

Regarding the latter, she said: "That worried me but I decided to trust in the care he was receiving, especially as they were trained professionals."

The inquest heard Jason had not been given anticoagulants - medicines that help prevent blood clots - despite being at risk of life-threatening condition deep vein thrombosis (DVT). When questioned by the coroner, Dr Sonali Dharia, a consultant neurologist at RD&E agreed there was no reason why he had not received anticoagulants and said he should have been given it due to his lack of mobility.

She added he had been prescribed surgical stockings to reduce the risk but had not been provided with any and it was not known why. It was also noted he only received one DVT assessment throughout his admission, despite his mobility having deteriorated to the extent he required two nurses to get him out of bed.

Dr Dharia conceded his fluid intake and urine output had not been adequately monitored or his catheter which became blocked during his stay. Concerns raised about his oxygen levels were also not acted upon.

Jason was found to be in cardiac arrest by ward staff on May 14 at around 8am having last been observed at 5.45am and was unable to be resuscitated. Dr Dharia said the level of observations was reasonable due to his vitals at the time.

Following his death, a consultant radiologist who looked at a CT scan that had been taken prior to Jason's death due to abdominal pain, detected blood clots in the lung. The cause of his death given was pulmonary embolism - a sudden blockage in a lung artery.

Susannah Faulkner, clinical matron at the RD&E, confirmed changes had taken place at the hospital and are continuing to be made following Jason's death and the findings of an internal review. These included updated DVT training for all staff, DVT risks being accessed every day, and immediate life support training.

Assistant coroner Stephen Covell concluded: "I find the risk of DVT was not addressed either by chemical or mechanical prophylaxis [treatment given or action taken to prevent disease] as it should have been, and this omission caused or contributed to the DVT forming."

He noted how important it was for accessing that risk for all patients in hospital, particularly those with compromised mobility.

He continued: "I consider this failure to deal with that risk is a failure to carry out what is basic medical treatment and basis medical care. I also find that this failure to care out the basic medical care caused or contributed to Jason developing the DPV which then became a pulmonary embolism which resulted in his death.

"Not providing Jason with this treatment, not reassessing him providing him with technical and/ or mechanical prophylaxis was a gross failure."

He added he was 'sceptical' as to whether it would have made a difference if the blood clot had been detected by doctors from Jason's scan the evening before his death, adding that at that time the area of concern was the bowel. Concerns over his oxygen and catheter care were not said to have caused or contributed to his death.

Recording a narrative conclusion that confirmed the facts surrounding Jason's death, Mr Covell said: "The deceased's death was contributed to by neglect in that he did not receive any chemical or mechanical prophylaxis against the development of a DVT which was required due to his significantly reduced mobility."

Mr Clovell said he would not use his powers as a coroner to issue a Prevention of Future Deaths report because he was satisfied with the changes that had and will take place.

Paying tribute to Jason after the inquest, his family said: "As a family, it is and will be extremely difficult to navigate a future without Jason. He was the most wonderful human, and his life was cut way too short, from no fault of his own. His humour, smile and love will always stay with us for the rest of our lives.

"We cannot put into words how much we love and miss him. Life will truly never be the same again."

The family was represented during the hearing by Lime Solicitors. Following the inquest, medical negligence solicitor Francesca Grossman, confirmed the family is looking into whether legal action against Royal Devon University Healthcare NHS Foundation Trust, which runs the RD&E, is 'appropriate'.

Speaking on behalf of the family, she said: “The inquest has highlighted a series of concerning failures in the standard of care provided during Mr Twist’s admission to hospital and established that neglect played a direct role in his death. The coroner determined his death resulted from a pulmonary embolism caused by a deep vein thrombosis that developed due to his immobility during his hospital stay.

"It is deeply troubling that although surgical stockings were prescribed to prevent this very risk, they were never provided – an omission that represents a basic failure in nursing care.

"Additionally, there was a lack of consistent monitoring and reassessment of Mr Twist’s condition, despite clear signs of worsening immobility and the well-documented risks of prolonged bed rest. These oversights reflect a breakdown in basic care practises, compounded by missed opportunities for intervention by multiple professionals.

“His family tried to raise their concerns to medical professionals on multiple occasions but felt like their voices were not heard. Within 24 hours of his passing, they knew negligence had played a role and felt compelled to seek justice for the pain and suffering he endured.

“Mr Twist was a fit and healthy man – a father, a son, a brother, a grandad and a partner. To go into hospital and deteriorate to the point of a preventable, fatal outcome is devastating. While no action can bring him back, they take some comfort in seeking accountability and ensuring lessons are learned from this tragedy.

“The family understands mistakes can happen, but this was not one isolated error – it was a series of professionals failing to address a basic care need. This is a sobering reminder of the importance of vigilance and accountability in clinical care. They put their trust in healthcare professionals, but that trust was gravely betrayed.

“His family has been robbed of their future with him. His children, the youngest only seven at the time of his passing, have lost their father. His mother has lost her son. His partner has lost her soulmate. His brother has lost a sibling. His grandchildren have lost a grandfather. Their grief is profound and enduring.

“Our thoughts remain with Mr Twist’s family as they continue to navigate this incredibly difficult time. We will support them every step of the way as they seek answers and accountability. Hospitals must do better. They must prioritise proper assessment, communication and vigilance to ensure no other family endures such a preventable loss.”