Dad bled to death after ‘massive clinical error’

Afather-of-four bled to death after falling over and cutting his head on his front door after a “massive clinical error” by a nurse at his local surgery, an inquest has heard.

Christopher Charles Evans, 56, had been dead for at least eight hours when he was found on Friday, April 9, 2016, by police after a neighbour heard a thud in the early hours of the morning.

Initially his death was treated as suspicious but the inquest heard it appeared Mr Evans had died after falling and hitting his head on a sharp edge of a door frame, which resulted in an 11cm long and 2cm wide laceration of his scalp. He was said to have died from blood loss.

Upon falling over and cutting his head, Mr Evans called Skewen Medical Centre at 11.23am to ask whether he could come in to get some stitches.

He was called back by nurse Susan Pugh at 11.30am who advised Mr Evans to attend the minor accident centre at Neath Port Talbot Hospital.

Mr Evans, of Terminus House, St John’s Terrace, Skewen, told Mrs Pugh he would ask his son to take him to the hospital when he finished work at 8pm, with Mrs Pugh insisting he shouldn’t leave it that long.

But acting senior coroner Colin Phillips labelled nurse Pugh’s advice as a “massive clinical error”, claiming the nurse “did not ask enough probing questions”.

He said: “Mr Evans should have been transferred to the doctor but the GP’s office went off protocol and asked for the nurse.

“We can only speculate that he would have survived if an ambulance had been called.”

Giving evidence at the inquest, Mrs Pugh said Mr Evans had seemed okay to her.

“When I spoke to Mr Evans he seemed fine,” she said. “I thought it was just a minor bump on the head.

“I should have told him to call an ambulance.”

Addressing Mr Evans’ son, who attended the inquest, she said: “I am deeply sorry for what has happened to your father.”

During the inquest a recording of Mr Evans’ telephone conversation with the nurse was played.

At this point Mr Evans’ son shouted out: “Why didn’t you phone an ambulance.”

The inquest heard how Mr Evans had a history of alcoholism, however, a toxicology report found no evidence to suggest he was under the influence of alcohol.

DC Craig Hughes, of South Wales Police, confirmed there was “no involvement from third parties”.

Mr Phillips returned a verdict of “accidental death with unintended consequences of his actions”.

Speaking after the inquest, Dr Heather Christine Potter of Skewen Medical Centre said the practice had tightened protocols.

She said: “On behalf of my practice I must express my deepest sympathies to the family of Mr Evans.

“As a practice, we have looked deeply at the sequence of events that led to Mr Evans contacting the practice on the day he did, what happened at the practice and also what happened following.

“We have tried hard to look at the protocols we had in place and also what happened to allow Mr Evans to fall through these protocols.

“These have now been tightened and there has been staff training to ensure the protocols are adhered to. These are now going to be reviewed on a regular basis in the hope that any similar events in the future can be avoided.”