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Man died after Royal London doctors ignored his symptoms

PUBLISHED: 12:24 16 June 2015 | UPDATED: 12:24 16 June 2015

Royal London Hospital

Royal London Hospital

Archant

Doctors missed out on many chances to save the life of a stained glass window craftsman who died of a rare complication after he fell off a ladder.

Edward Perry, 57, fractured his spine on February 28 2013 whilst trying to get a suitcase out of the loft at his home in Victoria Park Road for a holiday to Portugal.

His daughter was told by doctors at the Royal London Hospital in Whitechapel that his injury was very common and he would be out of hospital within a week, but by March 8 he was dead.

An inquest at Poplar Coroner’s Court heard how doctors failed to act on the fact that his stomach had swollen up by March 2 through paralysis of the bowel, a rare complication of spinal injury caused by surrounding nerve damage.

Eventually he suffered “catastrophic vomiting” and cardiac arrest.

Dr Bunker, ICU consultant and anaesthetist, who was drafted in after a year to lead the delayed investigation into his death, said it had been repeatedly noticed in the medical records he had a distended abdomen. He said: “We could have intervened more aggressively to prevent what happened on the night of March 7, the trouble is we continued a conservative approach on the 4, 5 and 6 despite him not getting better.”

However the barrister acting for the family said: “When you say the conservative approach was adopted regarding the abdomen, that’s not the case is it? There was no plan in place regarding the abdomen.” 
Dr Bunker agreed and went on to detail how junior members of staff now receive training on how to manage deteriorating patients, and how neurosurgeons are responsible “not only at the brain and nerves but the whole patient”.

There was also a recognition the major trauma centre was understaffed, as there was only one registrar working that night.

Coroner William Dolman recorded a narrative verdict, ruling Mr Perry died of an extremely rare complication of a spinal injury caused by a fall, which wasn’t recognised in time.

He said: “From the facts we are getting very close to neglect but we don’t reach the standard required by law. The real problem arose because the gravity of the clinical picture was not appreciated, the doctors saw the signs but didn’t recognise their significance.”

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