The Isle of Wight NHS Trust has apologised after an inquest into the death of a Newport man — four years on — found there were “egregious failings” in his care. 

On Friday (October 4), Coroner Caroline Sumeray concluded Martin Francis Cotton, 59, died of natural causes on March 18, 2020.

Although Mrs Sumeray said, on the balance of probabilities, Mr Cotton's death was not down to neglect, she expressed significant concerns about his care and the NHS handling of the subsequent Serious Incident (SI) Investigation.

Citing the pandemic, staff shortages and the building of the new coroners court at Seaclose, the coroner apologised for the delay in holding the inquest.

On March 1 2020, Mr Cotton, 59, was admitted to St Mary’s Hospital with chest pains and was found to have a lower respiratory tract infection.

He was discharged on March 10, but five days later his condition worsened and Mr Cotton’s wife, Sara, called an ambulance.

On this occasion, he was not admitted and in the days that followed, Mr Cotton's wife twice spoke to Dr Judith Moore, who offered GP advice, but decided against visiting him at home.

On March 17, she arranged for an ambulance to attend and, after a three-hour wait, Mr Cotton was re-admitted to hospital, where his condition worsened and he was diagnosed with multiple organ failure and sepsis.

The following day Mr Cotton suffered a cardiac arrest and was pronounced dead at 10.55pm.

Dr Moore, who is now retired, defended her decision not to attend Mr Cotton’s address, though the coroner said her conduct could be criticised.

Mr Cotton’s family, represented by Michael Spencer and Victoria Higgins, argued that sepsis played a role in his death, but there was no mention of it in his post-mortem, which found his heart to be twice the normal size.

In a statement read by Mr Cotton's wife Sara, he was described as a “devoted father," who enjoyed fishing, engineering and was affectionately named “Grandpa Tickle” by his many grandchildren.

Mrs Sumeray concluded Mr Cotton’s death was due to natural causes, primarily due to various health complications, chief among them multiple organ failure.

While acknowledging the medical errors made during his care, she concluded that they did not directly cause or contribute to his death.

She explained that Mr Cotton was already a severely unwell man, and even a minor infection could have overwhelmed his body.

Mrs Sumeray said the inquest was necessary because the Serious Incident (SI) Investigation into his death was “flawed".

It was conducted by a non-clinician, did not adequately address the hospital’s decision-making and was completed before the report writer knew what the cause of death was, she said.

Jeannine Johnson, the Trust’s clinical director, apologised for the omissions in Mr Cotton’s care, acknowledging the mistakes made during his hospitalisation.

“We offer condolences and unreservedly apologise for the omissions in care. There are no excuses.

"All we can do is make it better for patients in the future,” she said.

Mrs Johnson added that the Trust has since replaced SI Investigations with a new Patient Safety Incident Response Framework (PSIRF) to improve future care.