THE FAMILY of a retired policeman who died after being left on a trolley for five hours without being seen by a doctor is considering legal action against the hospital.
Father of three Michael William Poad, aged 64, of Rose Hill, Sticker, died on a hospital trolley in a cubicle in A&E at the Royal Cornwall Hospital in Truro on December 15, 2009.
Mr Poad had been brought to the hospital by ambulance suffering from excruciating abdominal pain.
At the inquest held into the former police constable's death on Friday Dr Emma Carlyon, coroner for Cornwall, ruled that neglect had played no part in his death.
A submission of neglect had been made on behalf of the family by their solicitor Mike Bird.
An earlier hearing, held in May, was adjourned after the family requested an independent expert attend. It emerged at the hearing that admission procedures at the hospital had been changed following Mr Poad's death.
Truro Coroners' Court was told that Mr Poad was brought to A&E in an ambulance at approximately 3.15am.
Paramedics had assessed his pain, described in court as the "worst pain ever", and had administered morphine by injection.
They had also taken blood pressures, which were slightly different, and checked for a 'hostile mass' in the abdomen, but found none.
The paramedics told the triage nurse in A&E they suspected Mr Poad might have been suffering from one of a number of possible complaints, including gallstones or kidney stones or an abdominal aneurysm.
A post-mortem examination revealed Mr Poad had in fact suffered a different type of aneurysm, known as a ruptured ascending aortic dissection, located in the chest.
At A&E he was seen by a triage nurse within ten minutes. The nurse took his blood pressure and carried out an ECG, which was recorded as normal. The triage nurse also administered a second dose of morphine when the pain returned.
The nurse treating him last saw Mr Poad at around 5am.
At approximately 7am he was moved from the bay opposite the nurses' station to another elsewhere in the department, where he was seen sitting up in bed and reading, but at around 7.45am, yet to be seen by a doctor, his pain returned and he called for pain relief.
Mr Poad was finally seen by a doctor at 8.10am after he had suffered a cardiac arrest.
The inquest was told that even if Mr Poad's condition had been diagnosed there was no guarantee he would have survived the trip to the operating theatre at Derriford Hospital, Plymouth, where the procedures were carried out.
James Kuo, a consultant cardiovascular surgeon at Derriford, said early diagnosis was important. "If you suspect anybody has an aortic dissection, you are triaged differently and dealt with as an emergency – as a priority – but if the diagnosis has not been suspected or considered ... then there is a tendency to categorise as slightly less urgent," he said.
A CT scan would "very likely" have shown an aortic dissection.
Mr Kuo said it could take from two and a half to four hours for a patient diagnosed in Truro to reach the operating theatre in Plymouth.
If the operation was successful there was a 60 to 70 per cent survival rate, he said.
Asked if beta blockers – drugs which reduce blood pressure and slow the heart rate – would have extended the window of opportunity for Mr Poad's survival, Mr Kuo said he could not say, but added: "If you lower the blood pressure, you lower the risk of the aorta rupturing."
Recording a narrative verdict, Dr Carlyon said: "Even if the diagnosis had been made, it is not clear to me that the outcome would have been any different.
"Based on the evidence, I cannot find a failure that is connected to the deceased's death."
After the hearing Mr Poad's family spoke of their disappointment and said they felt they "owe it" to him to pursue a civil case for negligence against the hospital.
His eldest daughter Alison, 38, said: "We feel relieved that it's finally over. We've waited two and half years to get to this stage and it's been very difficult. The ruling was as we expected but we don't feel it accurately reflected the course of events and we feel extremely disappointed in the trust and its level of care.
"We hope the new procedures that have been introduced as a direct result of our father's death are adhered to and they continue to make significant improvements."
Mr Poad's widow Diana, 66, said life was empty without him.
"When the ambulance arrived to take him to hospital I was actually relieved," she said. "My husband trusted them [the hospital]; we all did until this happened."
A spokeswoman extended the Royal Cornwall Hospital Trust's condolences to the family and said it had completed an internal review of Mr Poad's admission.
"It's led to a number of improvements including the introduction of a pain- scoring tool and changing the triage criteria for patients who require opioid analgesia on admission to urgent, rather than standard pain relief," she said.
