A 21-year-old NHS patient died after staff delayed his treatment and did not understand his sickle cell disease, a coroner has said.
Evan Smith died in hospital after dialling 999 from his temporary bed in a corridor after staff failed to give him a blood transfusion.
The football data analyst was admitted to North Middlesex University Hospital with jaundice on April 18, 2019.
The previous day he had been discharged following the removal of a stent after a gallstone operation, but died of organ failure a week later on April 25.
An inquest ruled his death was due to an infection in his bile duct which triggered his blood cells to sickle – meaning they change shape, take on far less oxygen, and pose a risk of blocking his arteries preventing his body from feeding enough oxygen to his brain.
At a hearing this week, a coroner ruled staff at the hospital “failed to appreciate the significance” of sickle cell symptoms and was told Mr Smith was not given a potentially life-saving blood transfusion until “damage had already happened”.
He was initially denied oxygen when he asked for it after complaining of hip pain – a symptom of the disease – and called the London Ambulance Service from a temporary “lodging bed” in a corridor begging to be transferred to A&E.
But paramedics did not come because his oxygen levels were not low enough and nurses were unable to move him to an intensive care unit because no beds were available.
The inquest also heard how, once his symptoms were properly recognised and medical staff scrambled to get him a transfusion, doctors were “distracted” from getting the blood exchange by trying to investigate an underlying infection.
Had he received the right treatment in time, “it is likely that Mr Smith would not have died when he did”, a coroner ruled.
Mr Smith, from Walthamstow, north east London, had a history of sickle cell disease.
The inquest heard how North Middlesex University Hospital NHS Trust has since introduced a specialist ward with staff trained to deal with sickle cell crisis.
Mr Smith’s father, who was by his side in the hospital and was today in the inquest with his wife, and Mr Smith’s mother, Betty, today read a heartfelt tribute to his only child.
He recalled a trip to Paris the family had taken for his son’s birthday, his academic achievements – including graduating from City, University of London with a bachelor’s degree in Financial Economics.
He also told of his love of sport – particularly football, his faith and church activities, and work with football news company Squawka.
He said: “Evan was an exceptionally conscientious and hardworking individual and had such a bright future ahead of him.
“Betty and I still have a lot of unanswered questions about his care and his death. We are unable to rest until we know why more was not done to save his life.
“We are therefore requesting a full and transparent investigation into our son’s death.
“We know that this can never bring him back, but we are hoping that lessons can be learnt, so that such a devastating and avoidable loss would not happen again to any other patient.”
Coroner Andrew Walker considered recording a conclusion of neglect but explained: “It’s not basic care that was lacking, it’s the wrong care. Or the wrong priority.”
Instead, he recorded a conclusion of “consequences of a sickle cell crisis in a patient with biliary infection”.
He added: “Mr Smith requested oxygen and, when this was not provided, telephoned the London Ambulance Service asking to be transferred to the Accident and Emergency Department and this is an indication of how concerned Mr Smith himself was.
“There was a failure to appreciate the significant of these symptoms by those looking after Mr Smith at this time.
“The delay in treating Mr Smith with a timely exchange transfusion was the cause of his death.
“This was made more difficult by a lack of understanding of sickle cell disease in the medical and nursing staff looking after Mr Smith and the need for a consultant haematologist to be available in the early morning of April 23.”
Gerry Boyle, representing the Trust, said: “It is accepted on the part of the Trust that the care they provide Evan on his admission fell below the Trust’s usual high standards and for that the Trust offers its sincere apologies on the loss of their son.”
Dr Emma Whicher, medical director at North Middlesex University Hospital NHS Trust, said: “We offer our sincere condolences and apologies to Mr Smith’s family.
“In 2019, we carried out a thorough internal investigation into Mr Smith’s care and treatment and we recognise that this should have been better.
“Since then, we have made a range of improvements, including introducing a specialist sickle cell area on one of our wards, providing extra training for staff around the disease as well as ongoing engagement with the local community who this disease disproportionately impacts.”