Patient ‘suffered more than he should have done in the last hours of his life’ at King's Mill Hospital

Mark Richard Hodgkin, 58, was “in incredible pain” with a large brain bleed when he was taken to the emergency department at 7.27pm on January 4, and he passed away at 5.22am the next day.

“I am sure he could have been saved if the CT scan had happened earlier and the bleed was shown,” his widow Amanda said. “There was never any urgency.

"How can someone with headaches, total loss of vision, and high blood pressure not be checked? It was obvious something was seriously wrong neurologically."

The inquest found Mr Hodgkin’s blood pressure was checked at 8pm and hypertensive crisis was diagnosed, but he was refused entry to the resus unit, possibly because there were 18 patients in an 11-patient area on a busy Saturday night.

At 9pm an inexperienced nurse told a consultant the patient was on chemotherapy (he hadn’t been for two years) but not about his blood pressure.

Amanda Bewley, assistant coroner for Nottinghamshire, said it was "concerning” the consultant was given “fundamentally flawed information,” which led to an incorrect diagnosis, but noted he failed to check the patient’s paperwork.

And although morphine was prescribed none was administered.

At 10pm Mr Hodgkin was reviewed by a second doctor who made the correct diagnosis, but it took until 3am for a CT scan to finally take place.

Mr Hodgkin’s condition was “not survivable” because the haemorrhage had been ongoing for too long and surgery would, at best, leave him in a permanent vegetative state.

The coroner concluded staff didn't contribute to, or cause, his death, but she was “not satisfied” with the care Mr Hodgkin received and neither was Sherwood Forest Hospitals NHS Trust.

None of the witnesses tried to cover for themselves, each honestly attempted to understand what went wrong and improvements have been implemented, she said.

But the urgency of the situation wasn’t understood and there was no adequate explanation why he was left without pain relief.

A conclusion of death by natural causes was recorded on Wednesday.

Offering her sincere condolences, the coroner said mistakes made by the hospital compounded Mrs Hodgkin’s grief and made it more difficult for her to deal with her husband's death.

The Trust apologised to Mrs Hodgkin, and said it has “identified significant changes, most of which have already been put in place to try to prevent similar issues happening again.”