Swine flu death of man sent home from NHS clinic

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

Although his oxygen blood saturation levels were “monstrously low” according to a coroner, 36-year-old Mr Mason was not immediately admitted to hospital.

A nurse practitioner thought he was “one of the sickest” cases she had seen but failed to alert a GP and just logged him on the computer as “high priority”.

But Dr Ali Kouchouk did not pick up on the note and, after diagnosing Mr Mason with viral enteritis, dehydration and an upper respiratory tract infection, sent him home with drugs.

Mr Mason, from Newton-le-Willows in Merseyside, was found dead the next day in the bed and breakfast accommodation where he was staying in Barnsley.

Dr Kouchouk was suspended by privately-run health care provider Care UK, which runs the Rotherham centre, but was later reinstated as an out-of-hours doctor.

An expert 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 could not say if he would have lived.

Nurse practitioner Michelle Jackson-Smith had only worked as triage nurse for a month.

During an examination of Mr Mason her pulseoximeter, 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, the inquest heard – but the nurse believed her equipment might have been faulty.

Nurse Jackson-Smith flagged up Mr Mason’s case on the GP’s computer as she did not want to interrupt him.

“There was no opportunity for a verbal handover, it was a very busy environment,” she said.

Dr Kouchouk said he was unaware at the time that there was a system for flagging up patients on the screen as “high priority”.

He denied the patient was struggling for breath and thought the pulseoximeter reading was so low because the battery needed changing.

He said he told the patient: “Mark, if you are not better today then you must come back today or go to the nearest hospital. I asked him to promise me that he would.”

Mr Mason was seen on Wednesday, December 15, 2010 and was found dead at 11am the next day. The cause of death was given as adult respiratory distress syndrome due to swine flu.

Dr Fletcher told the hearing: “If I saw those features in hospital, on balance, I would not send him home,” he said.

The inquest was adjourned.