Coroner tells East Mids NHS ‘get sorted’ after Derbyshire man dies waiting for surgery

Leicester Town Hall. Image by LDRS.

The death of a Derbyshire man with a “life of adventure ahead of him” has led to a coroner issuing an urgent warning to East Midlands NHS bodies to prevent future deaths.

Malcolm Budd, 65, died in hospital before surgeons could operate after suffering a tear in the artery – known as an aortic dissection – on February 24th of this year.

Coroner Dianne Hocking had the job of determining the facts around Mr Budd’s death at an inquest in Leicester’s Town Hall on Tuesday, October 20th.

After spending more than seven hours in the Royal Derby Hospital, he died awaiting surgery in Leicester’s Glenfield Hospital.

Coroner Hocking issued a Prevention of Future Deaths report before the hearing, urging better communication between local NHS bodies.

She said that, unlike the West Midlands region, the East Midlands lacks a “pathway” plan for this dangerous condition, and revealed that a “lack of agreement between local hospitals” has delayed “lifesaving treatment” in multiple cases this year.

Malcolm’s wife Alison Budd, a senior nurse and midwife, praised the efforts of hospital staff in Derby and Leicester, but told the court the process felt “chaotic”.

She said: “For me, this isn’t about blame – it’s about what we can learn from it.

“I get he was poorly and it was a hard diagnosis but I think he deserved the chance to fight. 

“I do feel that if we had got him there a bit earlier he would have had the chance.”

Mrs Budd told the court that the 65-year-old woke up that day “with a life of adventure ahead of him”, and said that the couple had recently reserved a plot for their “dream home” and were looking forward to travelling around Norway and New Zealand.

Mr Budd, known as Granpy to his family, arrived at Royal Derby Hospital at 12.26pm and was sent straight to the streaming room due to severe pain in the jaw, neck, and back.

Mr Budd was driven to hospital as no ambulances were available to get him there in a timely manner.

Dr Siddhu – a junior doctor – assumed his care at around 2.30pm and told the coroner that the hospital was busy that day and staff were under pressure.

After a discussion with his senior, Dr Siddhu suspected an aortic dissection and arranged a CT scan to diagnose this.

The mortality risk for this condition increases by one to two per cent every hour.

In line with hospital policy, Dr Siddhu contacted Nottingham-based cardiac surgeon Mr Hamed, who recommended a procedure called a frozen elephant trunk.

Mr Hamed said that scans showed Mr Budd had an artery tear of around five centimetres, and confirmed the diagnosis as soon as he was out of the scanner at around 6pm.

However, neither the Derby nor Nottingham hospital had capacity to carry out the required operation.

It was arranged for Mr Budd to be blue-lighted to Glenfield Hospital by ACCOTS, the dedicated Adult Critical Care Transfer Service for the Midlands.

They were at Mr Budd’s bedside by 7.30pm and arrived in Leicester at 8.26pm.

Glenfield cardiac surgeon Mr Zakkar intended to carry out a procedure contrary to what had been recommended by the Nottingham doctor, but as Mr Budd was on the stretcher awaiting the lift to theatre, he stopped chatting and started snoring, signalling a cardiac arrest.

Despite efforts to resuscitate him, Mr Budd died at 8.45pm that evening.

Coroner Hocking told representatives from the Nottingham and Leicester hospitals that while she is not the “referee” for arranging a plan of action for dealing with aortic dissection referrals from Derby, “make sure this gets sorted out”. 

She said that if a single point of contact had been there to oversee the case, Mr Budd could have got to theatre earlier, but this would not necessarily have changed the outcome.

Coroner Hocking concluded that his death was down to natural causes.  She said: “It’s obvious to me, who never met him, how much love he had. Malcolm sounds like a bloke who I would have liked to have known.”