A coroner has flagged "a clear missed opportunity" to give a poorly retired miner a better possible chance of survival, with escalation of treatment within a Nottinghamshire hospital. Paul Upex, 65, died at King's Mill Hospital, in Sutton-in-Ashfield, on April 27, 2022, four days after admission.
Nottingham Coroner's Court heard he had a high temperature, a productive cough, and left sided abdominal pain. He was treated promptly for sepsis, with a broad spectrum antibiotic, and fluid resuscitation. The initial source of the infection was unclear.
But Mr Upex, of Kirkby-in-Ashfield, became increasingly unwell, with a need for oxygen to maintain his blood oxygen saturations, and a diagnosis of pneumonia was made. By 8.30pm on Wednesday, April 26, he was very unwell, with a high National Early Warning Score (NEWS) of 8, the inquest heard.
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He had a high respiratory rate, a high heart rate, and was requiring very high levels of oxygen. Nottinghamshire assistant coroner Dr Elizabeth Didcock, in her findings, recorded: "Whilst there was a prompt response to this deterioration, with assessment, further oxygen treatment, and treatment with diuretics, there was confusion as to the plan as to where best to manage this deterioration, with regard to escalation or not to the Intensive Care Unit.
"There was an inaccurate assessment of his pre-morbid functional status. Whilst there was no clear indication for admitting him to the ICU at this time, the confusion as to whether or not the ITU team should have been recalled to further assess him then continued, with no further escalation to the team, when he further deteriorated at 01.30 hours on the 27th April 2022.
"At this time his critical clinical condition should have been re-escalated to the ICU team, and there should have been a discussion with the ICU and Haematology consultants on call as to the plan for Paul's further management. It is likely that the outcome of this discussion would have been his transfer to ICU at this time.
"Whilst it is not possible to say that this would have on a balance of probability led to a different outcome for Paul, it was a clear missed opportunity to give him a better possible chance of survival, with escalation of treatment".
The coroner found there was also "no subsequent escalation to the ICU team" at 4.06am on the 27th, when his oxygen saturation level fell to 86 percent, despite very high flow oxygen, as there should have been.
Mr Upex had a cardiac arrest at 4.30sm and had prolonged and full advanced life support at this time. Despite brief periods of return of spontaneous circulation, he did not recover and was pronounced dead at 5.30am.
He had a severe bronchopneumonia, causing Adult Respiratory Distress Syndrome, that had not responded to antibiotics and general supportive treatment, that of oxygen and fluid management. He had a number of underlying conditions that affected his ability to respond to the severe physiological stress of this infection.
The conclusion was a narrative one - that Mr Upex died from bronchopneumonia - despite treatment with antibiotics and oxygen. He had an underlying condition, that of myelofibrosis (a rare blood cancer). This, together with its treatment, made Mr Upex at increased risk of developing a severe infection.
Miss Didcock said he also had "underlying coal workers pneumoconiosis", caused by exposure to coal dust during his occupation as a miner. This also made a contribution to his underlying lung disease, and to his death.
Dr David Selwyn, Medical Director for Sherwood Forest Hospitals, said: “We would like to express our deepest condolences to Mr Upex’s family for their loss and offer them an unreserved apology at what we know will be an incredibly difficult time for them.
“We are committed to providing the best possible care to all our patients and we regularly monitor every patient in our hospitals to ensure their needs are regularly assessed and that any deterioration in their condition is highlighted at the earliest possible opportunity.
“We welcome the scrutiny that this Inquest has brought in supporting our own internal review of our care that we provided.”
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