NHS staff were too slow to treat man who rang 999 from his hospital bed, coroner rules – The Guardian


Evan Nathan Smith ‘would not have died if hospital workers had recognised sickle cell disease’

A patient experiencing a sickle cell crisis who rang 999 from his hospital bed after being denied oxygen would not have died if medical staff had recognised his symptoms and treated him sooner, a coroner has concluded.

Evan Nathan Smith, 21, from Walthamstow in east London, died in April 2019 in hospital after developing sepsis after a procedure to remove a gallbladder stent a week earlier.

Smith had the inherited sickle cell disease, when red blood cells become crescent-shaped, which can lead to health problems. The sepsis triggered a sickle cell crisis, which occurs when blood vessels to certain parts of the body become blocked. The disease is most common among people with African or Caribbean heritage.

Smith, a football stats analyst, rang the London ambulance service in the early hours of 23 April 2019 when he was being held in a “lodger” bed, which is a bed added to a ward for extra capacity as no beds were available, and did not have access to piped oxygen. However, the operator decided not to send paramedics.

When Smith was seen by a haematologist later that day, although he was prescribed oxygen, he was already entering the early stages of a sickle cell crisis. Smith did not receive an exchange blood transfusion until late on 24 April, and suffered a series of cardiac arrests on that same night.

He was confirmed to have died in the early hours of 25 April. The pathologist found his cause of death to be multiple organ dysfunction as a result of sickle cell crisis caused by sepsis.

The coroner, Dr Andrew Walker, concluded that the cause of Smith’s death was the delay in treating him with “a timely exchange transfusion”.

Smith’s parents, Charles and Betty Smith, outside Barnet coroner’s court on Tuesday. They said they would ask the hospital to investigate their son’s death. Photograph: Tess De La Mere/PA

He added that this was made more difficult “by a lack of understanding of sickle cell disease in the medical and nursing staff looking after Mr Smith”. This was despite the hospital where Smith was treated, North Middlesex hospital in Edmonton, north London, serving an area with a large African-Caribbean community. Walker added that there was “a failure to appreciate the significance of those symptoms by those looking after Mr Smith at the time”.

Despite the omissions of medical staff, the coroner did not make a finding of neglect.

Barnet coroner’s court heard that since Smith’s death, North Middlesex hospital now has a dedicated ward for sickle cell patients, and that staff in the wider hospital setting are receiving extra training.

Smith’s parents, Charles and Betty Smith, were present throughout the inquest. In a statement, Charles Smith said they were struggling with the loss of their only child.

“The death of someone you love is always sad, but the tragic way in which Evan died is something we will live with for the rest of our lives,” he said.

The couple said they would be requesting a “full and transparent” investigation into their son’s death by the hospital, and that they hoped lessons could be learned.

“We hope no other family would ever have to go through what Betty and I have, to see our only child pass before us so unexpectedly, in the hands of those that were supposed to care for him,” they said.













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