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HM Coroner Identifies Failings in the Treatment Provided to Robert Hart by Salford Royal Hospital

After an emotionally charged six-day inquest HM Coroner Mr Nigel Meadows found that festivalgoer Robert Hart was unlawfully killed. He also criticised the medical treatment provided to Robert by Salford Royal Hospital.

Slater and Gordon clinical negligence lawyer Zak Golombeck represented Robert’s mother at the inquest.

On 7 June 2014, Robert Hart and his girlfriend joined the masses of young people attending the annual Parklife Music Festival at Heaton Park in Manchester. Robert became involved in an altercation with another member of the crowd which resulted in him being punched one or more times and knocked to the ground, rendering him unconscious. He was resuscitated by an off- duty midwife and eventually regained consciousness.

Robert was taken to North Manchester General Hospital where he was assessed as having an acute head injury and admitted for neurological observations. The following day he underwent a CT scan which showed he had a significant subdural and sub-arachnoid haemorrhage. This is a serious and life-threatening injury.

Numerous attempts were made by North Manchester General Hospital to contact the regional specialist neurosurgical team at Salford Royal Hospital. Contact was eventually made just after midday and Robert was accepted for transfer to Salford. Unfortunately, the transfer was seemingly cancelled after the neurosurgical registrar requested that North Manchester General Hospital exclude any other injury before transfer because the doctor said he was unable to locate the head injury on Robert’s scans.

It was not until later that afternoon when the CT scan was reviewed by the neurosurgical consultant, that the seriousness of Robert’s head injury was noted and he was transferred to Salford Royal Hospital for emergency brain surgery. By this time however, he had suffered irreversible brain damage and sadly died on 11 June 2014. Robert was 26 years old.

Claim Against Salford Royal Hospital NHS Foundation Trust

Slater and Gordon are instructed by Robert’s mother, Elaine Hart, to pursue a claim against Salford Royal NHS Foundation Trust for alleged delay in diagnosis and treatment of the subdural haematoma. In particular, the claims pursued in this case are:

  1. A claim under the Law Form (Miscellaneous Provisions) Act 1934 for Robert’s estate for his pain, suffering and loss of amenity.
  2. A claim under the Fatal Accidents Act for his funeral expenses
  3. A claim on behalf of Mrs Hart as a victim in her own right for breach of Article 2 of the European Convention on Human Rights (right to life).
  4. A claim on behalf of Mrs Hart as a secondary victim.

The Trust undertook its own investigation into this matter and has admitted that arrangements should have been made to transfer Robert to Salford Royal Hospital earlier that morning at around 10.40am. If this had been the case, Robert would have arrived at Salford Royal Hospital by approximately 1:00pm and undergone surgery which, on the balance of probabilities, would have prevented his untimely death.

The Inquest

Evidence heard at the inquest included that of the midwife who managed to resuscitate Robert at the festival, Robert’s treating clinicians at North Manchester General Hospital and Salford Royal Hospital, as well as the coroner’s independent expert and the senior investigating officer involved in the criminal case regarding Robert’s death.

During the inquest, Mr Meadows commented that Robert could have survived had he been transferred to Salford Royal Hospital sooner. He also said the CT scan was misinterpreted by the registrar.

The inquest heard how staff at North Manchester General Hospital tried to get through to staff via the switchboard at Salford Royal Hospital for around 70 minutes.

Professor King, who led Salford Royal Hospital’s internal investigation into Robert’s death, admitted that there were a number of failings on the part of Salford Royal including technical problems with the PAC System (a computer network for digitalised radiological images and reports) and the interpretation of Robert’s MRI scan.

After hearing the evidence, Mr Meadows found that Robert “was unlawfully killed, but that there was a failure to provide timely and appropriate access to advice from either a neurosurgical specialist registrar or an on-call consultant, and a significant failure to adequately and appropriately interpret the CT images, which contributed to the death.”

Following the coroner’s verdict, Elaine Hart released the following statement:

“Robert died twice, once at the hands of his attacker and once due to the hospital’s failings. We cannot come to terms with that. If he hadn’t been attacked, he wouldn’t have needed to go to hospital, but with correct treatment he wouldn’t have died…His attacker has still not been found. The investigation is still on-going and if anyone knows anything we would urge them to contact Greater Manchester Police or Crimestoppers on 0800 555 111.”

Slater and Gordon solicitor Zak Golombeck represented Robert’s mother Elaine Hart at the inquest and commented that the inquest “highlighted a number of missed opportunities and failings in Robert’s care at Salford Royal Hospital that could have prevented his death.”

If you have any information about Robert’s death please contact Greater Manchester Police on 0800 555 111.

Charlotte Moore is a clinical negligence solicitor at Slater and Gordon Lawyers in Manchester.

Charlotte specialises in compensation claims arising from deaths and injury following negligent medical treatment.

If you or a member of your family suffered from negligent treatment in hospital, call our medical negligence solicitors for a free consultation on freephone 0800 916 9049 or contact us online.

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