On the 14th May 2014 the Coroner at the Inquest into the death of Brian Holland returned a narrative verdict. Brian died on 9th May 2013 after swallowing his upper dentures.As reported in today’s Manchester Evening News, Brian died on 9th May 2013 after swallowing his upper dentures.
Brian was a 44 year old man who had a history of myotonic dystrophy. His father was his primary carer and devoted his life to looking after him. Brian had been fitted with upper dentures and in May 2010 his father was concerned that he may have swallowed them after an episode of vomiting and took him to the A&E department of Stepping Hill Hospital. Professionals reassured his father that it was unlikely he had swallowed them and that it was more likely he had dropped them down the toilet when vomiting. He was advised that the dentures would not show up on an x-ray therefore it was pointless in sending him for this.
Within a month, Brian was taken back to A&E at Stepping Hill as he was having difficulty swallowing and had developed a lump in his throat. He was referred to the ENT clinic by the emergency department. Upon examining Brian’s throat, the ENT doctor concluded that he had not swallowed his dentures, but that the lump was simply part of his voice box.
Over the following months, Brian lost a considerable amount of weight due to difficulty eating or drinking. He was admitted to Stepping Hill in May 2011 for further investigations and was thereafter transferred to Wythenshawe Hospital in order for a feeding tube to be inserted. The doctors at Wythenshawe were initially unable to insert the feeding tube due to a blockage in his oesophagus. However, at no point had the doctors at Stepping Hill made their colleagues at Wythenshawe aware of the concern in 2010 about Brian’s missing dentures. Professor Martin, who carried out the feeding tube insertion, gave evidence that if he had been made aware the Brian may have swallowed his dentures, his findings would have been consistent with that risk and he would have arranged further investigations accordingly.
On Thursday 9th May 2013 Brian was taken to Stepping Hospital for emergency surgery after coughing up blood clots. Sadly, doctors were unable to save Brian. During the surgery, a foreign object was found lodged in his oesophagus. Post mortem examination revealed this object to have been the denture plate which had been swallowed in 2010 which led to massive blood loss. The dentures had, over the course of 3 years, worn through his oesophagus and caused a perforation in his aorta, the adjacent major blood vessel.
The Coroner concluded that had medical professionals properly identified that Brian had swallowed his dentures in mid-2010, following the A&E and ENT attendances, it was his belief that Brian would have survived the removal of the dentures whether by endoscope or surgically. He particularly noted that he considered Mr Harris, the ENT doctor, to have been arrogant in his evidence and the way he conducted his examination.
The Coroner indicated that he would write to the NHS Trusts involved, as well as to the Secretary of State for Health, to raise his concerns regarding:
1. The passing of information and patient details between healthcare professionals;
2. The rejection of Brian’s referral to the Speech and Language Team due to his learning difficulties;
3. The fact that dentures are not visible on x-rays or other imaging;
4. That an emergency endoscopy was not considered to have been standard procedure;
5. That not all doctors at Stepping Hill could access the medical notes as they did not have the necessary password;
6. That doctors at a hospital have no way of being aware of a patient’s attendances at another hospital – in this case that those at Wythenshawe were unaware of Brian’s A&E attendances at Stepping Hill.
Philip Holland, Brian’s father, commented that he was pleased with the Coroner’s findings and his intention to write to the agencies involved to highlight the errors that occurred.
This is a very tragic case and one that undoubtedly could have been avoided had crucial information been communicated between medical professionals involved in Brian’s care. This is not the only case recently in which similar concerns of this nature have been raised against this hospital and it is hoped that the Trust will learn from the mistakes made in the case and further deaths will be prevented.
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