An Inquest into the death of 40-year-old Richard Tredgett, which opened on 19 May 2021 at the North Yorkshire Coroners Court, concluded today with HM Coroner Jon Heath delivering a narrative verdict.
Richard, who had been working in York for a few days prior to his death, died on 20 June 2019 at Brighton’s Royal Sussex County Hospital as a result of a Haemopericardium due to an Aortic Dissection, which had been misdiagnosed by a hospital in York as costochondritis. He had suffered a sudden onset of severe chest and head pain, which had been enough to cause him a near collapse, and was taken by ambulance to the York District Hospital, but was discharged because the treating emergency department doctor had ruled out the possibility of Aortic Dissection, in part due to his young age and good general fitness. Richard had been discharged without further pain scores and observations being taken prior to his discharge.
During the course of his evidence, the treating doctor admitted that, now that he looked again, he should have picked up that this may be an Aortic Dissection and investigated further. In particular, he should have arranged a CT and aortogram and sought senior advice. It is Mr Paxton's case that, had this been done, Richard would have been transferred for urgent surgery and would have survived.
After Richard’s death, the Trust instigated a Serious Untoward Incident investigation. This concluded that there had been a misdiagnosis of Richard’s condition and set out a series of recommendations for change in relation to diagnosis of unexplained chest pain which include re-doubled efforts to raise awareness of Aortic Dissection and a requirement for anyone who attends with undiagnosed chest pain (over the age of 30) to be reviewed by a senior doctor prior to discharge.
HM Coroner Jon Heath delivered a narrative conclusion:
Mr Richard Tredgett attended the York Hospital on the 18 June 2019 and was discharged the same day. He attended his GP practice the following day. On the 20 June 2019 he was found to be unresponsive and was taken to the Royal Sussex County Hospital, Eastern road, but he could not be resuscitated. The cause of death was Aortic Dissection that had not been diagnosed prior to his death.
In view of the changed the Trust had implemented, as a result of Richard’s death, and the fact that Dr Crane, prepares the SUI report confirmed that the likelihood of such a misdiagnosis occurring again was nil, the coroner decided that it was not necessary for him to make a Regulation 28 report.
Mr Joe Paxton, a dependant of the deceased, instructed Shoosmiths to provide representation at the inquest. Sue Prior, a partner in Shoosmiths clinical negligence team commented:
“Joe and Richard were engaged to be married which makes Richard’s untimely and entirely avoidable death at such a young age even more tragic. HM Coroner Jon Heath agreed that there had been a misdiagnosis of Richard’s condition and that additional senior review and further investigations would have led to a correct diagnosis. It is our position that subsequent emergency surgery would have meant that, on the balance of probabilities, Richard would have survived. It is good to note that the Trust have recognised that mistakes were made and have recommended and implemented a series of procedures and increased their training measures to safeguard future patients.”
Joe Paxton, said:
“Richard’s death is a tremendous loss. We had been together for 4 years and were engaged to be married. Whilst nothing can bring him back to me, going through the inquest process and knowing that the hospital have investigated and made changes to their procedures has meant that I have been able to understand what happened to Richard and how this mistake was made. I sincerely hope that the changes will mean that this condition will be diagnosed in future patients and so prevent any further avoidable deaths from misdiagnosis of this condition. The coroner was very understanding of how difficult this process is and I am grateful to him and to my legal team at Shoosmiths for their support."
Pictured above: Richard Tredgett (left) and Joe Paxton (right).