That is the message from the heartbroken brother of Gary Heath who died at St James’ Hospital, in Portsmouth, after swallowing a hair comb.
An inquest into Mr Heath’s death heard how the 48-year-old died after hospital staff failed to act on a comment he made that he swallowed the comb.
He died less than a week later at Oakdene Ward from acute inflammation of his chest tissue after his oesophagus was ruptured by the foreign object.
Mr Heath, from Southsea, suffered from long-term mental health problems and had been at St James’ Hospital since 2008, the inquest heard.
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On August 12, 2012 he told a nurse he had swallowed a comb but when she questioned him about it, he said he was not sure if he had.
It was decided not to take Mr Heath to be examined and, on advice from an out-of-hours doctor, it was agreed staff would keep an eye on him.
The inquest heard during the following week, staff did not mention the comb incident to other clinical staff including Mr Heath’s psychiatrist. It was also not mentioned at a meeting between ward staff.
On August 18 Mr Heath collapsed and stopped breathing. A post-mortem examination found that Mr Heath had a comb in his stomach.
Giving evidence at the three-day inquest Dr Simon Toh, a consultant surgeon, said if staff had taken Mr Heath to hospital when he mentioned he swallowed the comb, an X-ray would have confirmed what he said.
He added that if an operation had been carried out, and nothing went wrong during the surgery, it was more likely Mr Heath would have survived.
Mr Heath’s brother Tony, from Gosport, said: ‘The inquest has given a lot of answers to the questions we had about Gary’s death. It has given the family and his close friends closure.
‘I am satisfied with the investigation carried out into Solent NHS Trust and I am happy lessons have been learnt and other families won’t suffer like we did.’
Paying tribute to his brother, Tony added: ‘Gary was a much-liked person. He was always very outgoing and was much-loved by all the family and his friends.
‘Although his mental health issues were a serious problem for a long time, we were always close. He is missed by us all and we remember him dearly.’
A jury gave a narrative verdict at the inquest. The foreman of the jury said: ‘Gary Heath did swallow the comb and told staff on the ward that he had done so. There was an opportunity for Gary to be taken to hospital to get further treatment but this did not take place.
‘From the expert medical evidence it was more likely than not that Gary would have survived if the comb had been removed at that time.
‘There were several more opportunities to take Gary to hospital.’
Coroner David Horsley gave his sympathies to Mr Heath’s family and said he was satisfied with the actions taken by Solent NHS Trust since his death and the changes they had made.
Sarah Austin, Solent NHS Trust’s chief operating officer and commercial director, said: ‘I would like to express sincere condolences to Gary Heath’s family. The death of a loved one is a cause of sadness, for which we are deeply sorry.
‘We take all cases extremely seriously and this matter was robustly investigated. Indeed, the coroner acknowledged we have made significant changes to our processes and procedures since the incident and expressed satisfaction with our remedial action plan.
‘Nevertheless, we will continue to reflect on the coroner’s conclusions and consider any further lessons.’