A grandfather died waiting for a life-saving brain operation after another patient was prioritised over him, an inquest heard.
John Brackenbury, 70, suffered a severe bleed on the brain and needed surgery which usually treats the condition in 48 hours.
But the procedure to place a metal coil in the aneurysm, so it cannot fill with blood, was postponed and he died after the bleed worsened.
Consultant neuro-radiologist Dr Yogish Joshi told an inquest at Norfolk Coroners last week that Mr Brackenbury, of Lodge Road, Feltwell, was likely to have survived had he been operated on earlier. He said the urgency may have been ‘lost in communication’.
Norfolk Area Coroner, Yvonne Blake, concluded Mr Brackenbury’s death was ‘an individual rather than systematic failure’.
In a statement his family said: “The nature of how he died and the suffering he endured haunts us all. Indeed, what is most tragic is that his loss was so avoidable.”
Mr Brackenbury attended Queen Elizabeth Hospital (QEH) in King’s Lynn on November 18, 2016, with ‘crushing’ headaches.
He was referred to Addenbrooke’s Hospital, Cambridge, after collapsing on November 29 with a cerebral bleed. An appointment was made for brain surgery on December 1 but he died on December 2.
Dr Joshi, consultant neuro-radiologist at Addenbrooke’s, explained the highest risk of a further bleed is within 24 hours of a haemorrhage, then risk gradually diminishes.
He said Mr Brackenbury’s operation was cancelled because doctors mistakenly believed he suffered a haemorrhage at the QEH, weeks before being admitted to Addenbrooke’s, so another patient was prioritised.
But consultant neurosurgeon Rikin Trivedi said it was ‘inconceivable’ the doctors would not have been made aware of the recent bleed, adding: “It is never not clear.”
The coroner said she found the evidence from Dr Joshi ‘vague and unconvincing’.
When looking at whether the hospital had been neglectful, Ms Blake said: “He [Mr Brackenbury] had been diagnosed promptly with an aneurysm which needed specialist treatment for which he was waiting.
She added: “It cannot therefore, in my opinion, be proper to say that the clinicians/hospital were grossly neglectful in his treatment.”
Delivering a narrative conclusion, Ms Blake said Mr Brackenbury died of a cerebral haemorrhage whilst awaiting specialist treatment.
Tim Deeming, a specialist medical negligence lawyer from Slater and Gordon, which represents the family, said:“An apparent catalogue of failings led to his unnecessary and avoidable death given that his treatment was not prioritised to comply with the national guidelines.
“We hope lessons can be learned from the failings in this tragic case across the NHS to ensure that improvements are made.”