Man died after five-hour St George's Hospital wait, inquest hears

Frank Parrott, 66, died on May 27 this year after a communication breakdown meant he did not receive the correct treatment after he hit his head in a fall, the inquest heard.

The incident sparked a serious untoward incident investigation (SUI), which found a catalogue of errors and led to a structural overhaul at the hospital.

Outside court, Mr Parrott’s daughter, Samantha, said: “I think they failed him terribly. We will never know. If more had been done, I might still have had my dad for another 20 years.”

The court heard how Mr Parrott, of Nightingale Lane, was taken to A&E on Tuesday, May 26, after being found with a nose injury on Clapham Common.

Dr Ros Given-Wilson, who conducted the investigation, said a computerised tomography (CT) scan was originally recommended at around 10pm, but it did not materialise until 2.40am.

By that time doctors realised the hemorrhage was too far advanced to operate, and he died at 1.19pm that day.

She blamed a series of communication errors between doctors which led to a radiology doctor rebuffing the first scan request.

Mr Parrott was also taking the blood-thinning drug, Warfarin, which can increase the risk of head bleeding - but this was not considered in his initial assessment.

The coroner, Dr Shirley Radcliffe, said: “Mr Parrott has died as a result of a fall. There had been errors made that may have made a difference to the outcome but it’s an accidental death which has been made worse for the family by the fact that they did not know if it could be changed.”

She recorded a narrative verdict, stating that he died of an intracerebral hemorrhage and it was not recognised that earlier treatment was necessary even though he was taking Warfarin.

She said: “It doesn’t bring back your father but hopefully we have some answers and some reassurance that things have changed.”

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