The Isle of Wight NHS Trust insists it has made changes after an inquest into the death of a Ryde man — six years after he died — heard there were “deficiencies” in his care.
Coroner Caroline Sumeray yesterday (Monday) concluded Alfred Douglas Goddard, of Argyll Street, died at the age of 54 of natural causes on August 19, 2017.
Although she said his death was not down to gross failure to provide medical attention, it was heard how two Serious Investigations (SI) found the care he received at St Mary’s Hospital was below standard.
The inquest was told how the NHS Trust ordered a second review into Mr Goddard’s care, after rejecting the findings of the first, internal investigation.
Author of the first report, Dr Michael Terry, a consultant at St Mary’s Hospital, Newport, said he suspected the death “was avoidable” and thought the trust had asked for a second investigation because his findings were “too candid”.
This, Covid lockdown, and, on one occasion, the coroner falling ill, were among the reasons for the delay in the inquest being heard.
The court was told how, on August 3, 2017, Mr Goddard was taken to St Mary's with diarrhoea and vomiting.
He was responding well to treatment but, three days later, he deteriorated and suffered a cardiac arrest.
Although Mr Goddard was resuscitated within 25 minutes, the "downtime" led to brain damage, the inquest heard.
On August 16, 2017, he was taken to Mountbatten hospice where he died three days later.
After Mr Goddard's family raised concerns about his care, an SI was launched by the trust.
Dr Terry found Mr Goddard's treatment in the first 24 hours was good but in the following days there were staffing issues, "inadequate" record keeping and a reluctance from staff to contact senior doctors.
A second report, carried out externally by Dr Chris Roseveare, also found Mr Goddard's care was below standard.
But, on the balance of probabilities, his death would not have been prevented by different management, the findings said.
Matron Rosemary Goulding, on behalf of the trust, said changes have been made since, including extra nurses, improved record keeping and measures to ensure senior staff review patients regularly.
Mr Goddard's sister, Sarah, said she was "shocked" that "basic levels" of care were not already in place and asked why.
Matron Goulding said the trust, which was in special measures at the time, relied heavily on agency staff and many shifts were unfilled.
Mrs Sumeray said she could find no gross failure to provide medical care such that it would have prevented Mr Goddard's death.
She concluded he died of natural causes.
Mr Goddard's wife, Helen, paid tribute to her husband and said she felt his death was "premature".
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