Son died in Egyptian swimming tragedy
Inquest jury rules he drowned due to poor medical care
AVULNERABLE Valley man died after receiving ‘insufficient medical care’ after suffering a seizure while swimming on holiday in Egypt, a jury heard.
Greg Stephen Roult died while on holiday at the Hotel Sonesta in Sharm-el-Sheikh, in March 2015.
The 27-year-old, who had epilepsy, suffered a seizure when he was in the hotel’s swimming pool while accompanied by two carers.
Greg was brought out of the pool and regained consciousness but after he then stopped breathing, a doctor incorrectly carried out CPR and both paramedics and hospital doctors failed to carry out treatment.
His parents Stephen and Angela have waited more than five years for answers and this week, following a series of delays, an inquest was held at County Hall in Preston.
The inquest heard Greg, from Waterfoot, was ‘happy, loving and caring and enjoyed a number of activities’, including swimming, and would regularly visit local pools accompanied by two Lancashire County Council (LCC) carers.
In March 2015, his carers Kim Sloane and Andrea Anderson decided to take him on the Thomas Cook holiday to Egypt so that Greg was away from home while it was being re-decorated - something he would have found distressing.
The inquest heard while Greg had an up-to-date Risk Assessment on his file no specific assessment was carried out for the holiday.
The carers described during the inquest how they were confident in taking care of Greg when he went swimming and would go in the pool with him in case he suffered a seizure. In the 12 months leading up to Greg’s death he had suffered 80 seizures, five of them in a swimming pool, but these were successfully managed by his carers.
The inquest heard the location of Egypt had been chosen because of the weather and hotel facilities. The group flew out from Manchester Airport and spent much of their time by the ‘Cactus Pool’ - because it was close to their accommodation, it was quieter and had a bar/cafe.
On March 26 the two took Greg into the pool where he went swimming, played with his ball and had a drink of milk at the swimup bar. He had started to swim under water but when his carers hadn’t seen him for “one or two seconds” they realised he was unconscious. Greg was pulled up and out of the pool and vomited before regaining consciousness. However, he lost consciousness again and his carers, along with other tourists, started CPR.
The hotel’s doctor then appeared, but a number of guests reported that his method of chest compressions was incorrect and equipment he used faulty.
Michelle Platt, an experienced Intensive Care nurse, noted the doctor incorrectly placed his hands on Greg’s stomach, which caused him to vomit again. The doctor then wrongly inserted a breathing tube and Mrs Platt said he used a suction machine incorrectly and it failed to work.
When two paramedics arrived, around 30 minutes later, they placed Greg on the stretcher by “grabbing his arms and legs”, Mrs Platt said, instead of the standard ‘roll’ method.
The paramedics then began to walk the stretcher back to the ambulance. Their lack of urgency led Greg’s carers to “take control of the stretcher and run with it to the ambulance”.
Both Miss Anderson and Miss Sloane said “no active treatment” was carried out in the ambulance during the 10-minute trip to Sharm International Hospital.
“The carers recalled arriving at the hospital and being left in a corridor,” Area Coroner James Newman said.
“After 10 minutes they pushed their way into the cubicle and found doctors standing around Greg but carrying out no treatment. A further 10 minutes later a doctor came and told them Greg had passed away.”
The coroner highlighted the “hugely contradictory” evidence from hospital doctors who claimed they had attempted to resuscitate Greg for 40 minutes, despite him having died after 20 minutes.
During the inquest medical experts agreed Greg had likely suffered a seizure in the pool and had a ‘near drowning’ event, but then recovered. However, either a subsequent seizure or injury caused by the near drowning “led to a catastrophic deterioration”.
A&E consultant Dr Phillips told the inquest that the hotel doctor’s CPR method “fell far below the expected standard” and that attending with faulty equipment was “worse than attending with no equipment at all because of the time wasted”.
The coroner explained to the jury that the delay in holding the inquest had been a result of difficulties in tracing witnesses in Egypt and a lack of evidence from the hotel and hospital.
He also revealed that LCC had carried out an internal review following Greg’s death which had identified that more information about the holiday could have been obtained and a more specific Risk Assessment should have been carried out before the trip.
The jury ruled that Greg Roult died as a result of drowning caused by insufficient supervision and inadequate medical care.
They concluded: “The holiday guidelines were completed by carers with the destination agreed by Greg’s mother. A swimming risk assessment was reviewed as part of these guidelines but was not tailored for the trip to Egypt and the associated risks. No risk assessment was listed with these guidelines.
“These guidelines were signed and authorised by three separate managers, despite risk assessments not being listed.
“Whilst Greg’s carers conducted an on-site risk assessment relating to depth of pool, proximity of room and availability of refreshments, this pool did not have a lifeguard and was a considerable distance to the doctor’s clinic.
“After a duration of time in the pool visual contact from carers was lost with Greg for an unclear amount of time. Taking into account the statements it is deemed the carers were not in reasonable proximity to provide immediate support.
“Following Greg’s removal from the pool he became conscious but deteriorated after a period of time. On the basis of the medical advice we believe that the CPR and assistance provided by carers and other British tourists was sufficient. The on-site doctor’s intervention and equipment are deemed not fit for purpose. This resulted in a carer and a tourist taking over the CPR.
“Following this the medical provision provided by the Egyptian healthcare was inadequate due to no CPR by the ambulance crew. The hospital has been misleading on the amount of time and level of care that Greg received, which we believe on the balance of probability to be inadequate.”
The coroner said he would send a Prevention of Future Deaths report to the Foreign and Commonwealth Office and the Association of British Travel Agents. Mr Newman said he would also forward the report to the Hotel Sonesta and Sharm International Hospital.
After the inquest, Greg’s father Stephen said he believed LCC were at fault.
“I don’t think they should have taken him to Egypt,” he said.
“Greg had been to Tenerife with his parents and carers. We have taken him for 10 years and the carers have been with us twice to Tenerife so there would have been more suitable. The hotel let Greg down terribly; to have a doctor that can’t do CPR, it’s unbelievable. The hospital staff, ambulance staff, they had no idea what they were doing.”