David Harding, a Leeds United fan, had travelled to England from Australia with his wife and daughter for the first time in five years to visit relatives. He was looking forward to seeing his older brother and finding out details for his family tree but did not get the chance to do so.
An investigation by the Parliamentary and Health Service Ombudsman (PHSO) found that the doctors who treated him “failed in their care”. While the Ombudsman could not say David’s death was avoidable, it found that he was denied the opportunity for treatment that could have led to his survival.
Ombudsman Rob Behrens said: “This is a tragic case of a man and his family expecting to enjoy a holiday and quality time with relatives which ended in bereavement instead of reunion.”
The Ombudsman’s investigation found David was inadequately assessed both in A&E and when he was taken to the ward.
Clinicians in A&E also didn’t consider information from the paramedics or nurses. That information would likely have led them to order a CT scan of his head which would have shown signs of a stroke.
While on the ward, there was no attempt to investigate David’s neurological symptoms. He was then given drugs that can cause haemorrhage for people who have had a stroke.
David was only seen by a consultant 19 hours after his arrival – five hours later than medical guidance advises. It was at this late stage that a stroke was suspected and a CT scan arranged that led to his diagnosis.
Staff did not keep David’s family informed about the seriousness of his condition. This meant they couldn’t spend time with him when he was conscious or say goodbye.
David had been a pit worker in Doncaster and served three years in the army before leaving with his wife, Sandra, in 1971 in to Australia. They settled in Perth and raised three children.
Sandra, 82, a retired business owner, said: “David was fit and well before we left Australia. The day before he became ill, he had been watching his favourite football teams Leeds United and West Coast Eagles.
“The next morning, I found him on his knees holding his head and called the ambulance. The whole experience with the hospital has been absolutely dreadful.”
Mrs Harding said she has lost 16kg through stress as a result of the experience, adding: “I will never forget what happened.”
The Ombudsman recommended that the NHS Trust acknowledge its failings and apologise. The Trust was also asked to pay a financial remedy to David’s family and put in place an action plan showing how it would learn.
The Trust has complied with all these actions.
Richard Robinson, Chief Medical Officer at Mid Yorkshire Teaching NHS Trust, offered his “sincere condolences” to the family and added: “Ensuring our patients receive the best possible care is our priority. We acknowledge that the care provided to David did not meet the standards expected. Actions have been put in place to make improvements.”
