AN inquest into the death of Gavin Andrew, who died at Tunbridge Wells Hospital, concluded on Thursday (February 1) with a finding of ‘neglect’.
Gavin Andrew, 43, died on November 7, 2022 from an infection of the epiglottis, which caused his airway to shut.
He had been taken to the hospital on October 25 with uncontrolled dribbling, a swollen and painful throat, difficulty speaking and an inability to swallow.
He had initially been told by staff at the hospital that the swelling in his throat was ‘probably an infection’. He was given painkillers and sent home.
Mr Andrew’s condition deteriorated, and he was taken back to the hospital later that day struggling to breathe. This was when doctors diagnosed him suffering from epiglottitis, a swelling of a flap of tissue at the back of the throat.
Medics tried to insert an airway, but by then Mr Andrew had suffered a brain injury due to lack of oxygen and was placed on life support. He never regained consciousness and died twelve days later.
Emma Andrew, Mr Andrew’s widow, described the father-of-two as “having a larger-than-life personality and an infectious laugh.”
She added: “I cannot put into words the void his death has left every single day.”
Mr Andrew’s family was represented in the hearing, which began on January 31, by James Cahan of Tunbridge Wells law firm, Thomson Snell & Passmore LLP.
The inquest began with a statement from the Maidstone and Tunbridge Wells NHS Trust. It admitted if Mr Andrews had not been discharged, he would have been observed further and identified as needing intervention. The statement also said when he returned to the hospital there was a failure in his care due to ‘a paediatric emergency’.
The Trust statement added: “With subsequent care his death would have been avoided”.
Following the coroner’s findings, medical negligence solicitor James Cahan, Partner at Thomson Snell and Passmore told the Times: “In my experience it is rare for a coroner to make a finding of neglect in a situation like this.
“The first part of the legal test the coroner must apply, is that there was a gross failure (that is, more than a simple error) to provide basic medical attention to the patient, who was in obvious need. In this case the obvious need was the fact Gavin was drooling uncontrollably from the mouth, so much so, he had a towel around his neck. The basic medical attention he needed was to be admitted for observation.
“The coroner also has to be satisfied that there was an opportunity to provide care that would have avoided death, and in this case the coroner stated in court that he was satisfied there was a clear and direct causal connection.
“I understand from the Trust that the tragic events surrounding Gavin’s death may be used as a case study, and shared nationally, as part of the training for staff in emergency departments, to avoid similar situations arising in the future.
“The family would like to say that Gavin’s case highlights the need for people to be their own advocate when they go to hospital, or their GP, and if they are concerned about the advice they have been given, to seek a second opinion.”
A spokesperson for MTW NHS Trust said: “Our thoughts remain with the family and friends of Mr Andrew, and we are deeply sorry that his care fell short of the standards our teams work hard to provide.
“The Trust has taken a number of immediate actions which include providing staff with additional assessment and simulation training.
“We will also review the findings of the coroner to ensure we continue to learn and develop our care and once again offer our sincere apologies and condolences.”
