Inquest into 'sudden' death of Fareham dad, 45, is halted after a gaffe with medical notes

‘Caring’ Clive Armstrong, of Fareham, died at Queen Alexandra Hospital on May 2 following a fatal blood clot in his lung.

However, an inquest hearing at Portsmouth Coroner’s Court yesterday had to be adjourned after it was revealed a key CT scan included as part of his medical evidence was that of another patient.

Coroner Rosamund Rhodes-Kemp told the virtual hearing: ‘I want to sincerely apologise to the family that this has arisen now and that I understand how difficult that is for you.

‘I don’t underestimate the amount of emotion that you may have invested in this particular aspect. All I would say is that it is not, sadly, uncommon and I have merrily prepared for inquests based on two or three bits of paper in a bundle and then found they don’t relate to that person at all.

‘So, it’s not uncommon but it is unfortunate to say the least and I’m sorry, very sorry. But we will get to the bottom of it and we will regroup as soon as we can.’

The mistake has forced an apology from Liz Rix, chief nurse at Portsmouth Hospitals University NHS Trust, who vowed to launch an investigation.

She said: ‘We understand how distressing it can be losing a loved one, especially while visiting has had to be restricted due to the Covid-19 pandemic.

‘This result was incorrectly recorded within Mr Armstrong’s notes and we will investigate internally how this took place and take steps to ensure it does not happen again.

‘Our sympathies are with Mr Armstrong’s family at this difficult time.’

The inquest heard 45-year-old labourer Mr Armstrong had traveled to hospital on April 23 after feeling ill and developing mysterious bruises on his stomach.

But while at A&E, the father of two suffered a devastating seizure and was placed into an induced coma.

Doctors diagnosed him with throbotic thrombocytopenic purpura (TTP), a rare blood disorder that causes blood clots to form in small blood vessels throughout the body.

These clots can be fatal if they block vessels and restrict blood flow to organs such as the brain, kidneys, and heart.

After three days in intensive care, he was brought out of his induced coma.

A CT scan on April 26 revealed he had suffered a small bleed on his brain and when he awoke, he appeared increasingly ‘distressed and confused’, the court heard.

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Mr Armstrong was later moved to a general ward on April 29 and appeared to be making a recovery – with medics saying he would be discharged on May 5.

But the devoted dad suffered a ‘sudden’ and ‘unexpected’ medical episode on the morning of May 2 and died in his hospital bed at 9.30am.

Dr Tanya Cranfield, a consultant haematologist at the hospital, said doctors had no idea where and when the fatal clot had first formed and insisted it didn’t appear on any of his CT scans.

A scan on April 24, included in Mr Armstrong’s medical report, did identify a clot in a pulmonary artery.

However, Dr Cranfield admitted during yesterday’s hearing that this scan was in fact of another patient with Covid-19 had been included by mistake.

She added: ‘We were all very shocked by his death. He was getting better. We were not expecting him to suddenly die. We really weren’t.

‘We were completely unprepared for this. It really came out of the blue.’

In a statement to The News following the hearing, Clive’s mother Sandra said her family had been devastated by his death.

The 68-year-old former nurse said: ‘Clive was an extremely caring and thoughtful man who lived for his children. He worked hard as a labourer to provide for them but any spare time he had would be spent with them.

‘His death has been completely devastating for the whole family. We are struggling to come to terms with it and have so many questions about the care he received.

‘The hardest part is knowing that he was alone as the family were not allowed to visit.

‘I am distraught that I did not get to see Clive before his death and that he died having spent a number of days in a confused and distressed state.

‘I am concerned that this was a warning sign that there was something seriously wrong.

‘Clive was an extremely dedicated father and would have fought to live so as a family we need to understand why we lost him.’

The family has since instructed solicitors specialising in clinical negligence at law firm JMW to investigate the care provided to Mr Armstrong.

The hospital has been given 21 days to investigate the medical report error.

No date has been fixed for when the inquest will resume.

A message from the Editor, Mark Waldron

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