‘Series of failures’ as another patient dies at Rotherham NHS Centre

Mark Mason, 36, had been in bed for a week, was not eating or drinking, could not walk unaided and was struggling to breathe when he turned up at the centre, an inquest heard in Sheffield.

Although his oxygen blood saturation levels were found to be abnormally low, the normally fit kick-boxer was not given oxygen or admitted to hospital.

At an inquest last month the same Rotherham NHS Walk-In Centre was criticised by the Rotherham coroner, Nicola Mundy, after a GP at the centre and two hospital doctors missed three opportunities to save the life of baby Lewis Mullins, who had chicken pox.

After Mr Mason’s death on December 16, 2010, GP Dr Ali Kouchouk Kouchouk was suspended by privately-run health care provider Care UK, which runs the walk-in centre, pending an internal inquiry. However, he was reinstated as an out-of-hours doctor.

A consultant in emergency medicine, Dr Alan Fletcher, told the hearing that if Mr Mason had been given immediate hospital treatment he would have survived longer, but he could not say if he would have lived.

Recording a narrative verdict, Sheffield coroner Chris Dorries identified four failures as “more likely than not contributing to the death of Mr Mason, occurring when it did”.

Those failures included a lack of training for a triage nurse and a failure to communicate important information between the nurse and doctor.

The inquest heard nurse practitioner Michelle Jackson-Smith had only worked as triage nurse assessing patients for a month and had not been trained in the job.

During a five-minute examination of Mr Mason, her pulse oximeter, which measures the oxygen saturation levels of a patient’s blood, gave a reading of 62 per cent. Anything below 92 per cent is considered serious.

But the nurse believed her equipment was faulty and did not check the accuracy of the reading.

Although she thought Mr Mason was one of the “sickest cases” she had seen, instead of walking a few yards to speak to the doctor she flagged up the case on the GP’s computer as she did not want to interrupt him.

The coroner said this lack of direct communication with the GP was another serious failure.

Dr Kouchouk said he was “concerned” for the patient but did not feel he was seriously ill.

He also did not check the oxygen saturation levels, believing the pulse oximeter had a flat battery, which the coroner said was a “significant missed opportunity”.

The doctor also went along with Mr Mason’s wish not to be sent to hospital.

Mr Mason, from Newton-le-Willows, Merseyside, was seen at lunchtime on December 15, 2010, but he was found dead at 11am the next day in his Barnsley bed-and-breakfast accommodation by his father.

The cause of death was given as adult respiratory distress syndrome due to swine flu.

Dr Fletcher told the hearing that Mr Mason would have been showing early signs of swine flu 24 hours before his death.

“If I saw those features in hospital, on balance I would not send him home,” he said.

Asked by the coroner if he would have survived had he gone to hospital, Dr Fletcher said the treatment for Mark’s condition was “challenging” and added: “With some degree of certainty he would not have died when he did because those interventions would have been sufficient to support his life.”

Since Mr Mason’s death, the walk-in centre has introduced new systems including formal induction programmes for new staff and a training programme for triage nurses.

Maureen Jamieson, a retired general manager of the centre, admitted there had been “organic difficulties” because of the new concept of walk-in centres. The coroner said he accepted changes had been made, but added that he would be writing to the Chief Medical Officer about the case.