The inquest into the death of 27-year-old professional rugby union player Ian Michael Williams concluded at the Doncaster Coroner’s Court on Monday 17 February 2020. The inquest had been adjourned following a request that the Coroner’s appointed expert in cardiology give evidence in person.
Previously the inquest had heard how Ian died on 20 February 2018 during a training session at English Championship Rugby Club, Doncaster Knights.
Before proceedings were adjourned, the inquest had heard from the expert in emergency medicine instructed by the Coroner that he considered there was “a seriously gross failure of care” by Doncaster Royal Infirmary in discharging Ian, compounded by not even providing him with appropriate advice and information on the life-threatening nature of his suspected condition. Given his symptoms, the expert’s view was that Ian should not have been discharged at all, but kept in hospital for further emergency treatment which may have included surgery.
HM Assistant Coroner Mrs S L Slater delivered a narrative conclusion of death from natural causes but throughout proceedings and in her concluding remarks she was very critical of the poor record keeping of the treating doctors at Doncaster Royal Infirmary and she rejected their verbal evidence that although there were no notes in the medical records, they advised Ian to avoid physical exertion. The “very poor documentation'' meant there were no notes about physical examinations, a management plan or any discussions between the clinicians and Ian himself.
Mrs Slater said: "Given there's no documentation in regard to the avoidance of exercise and the significance of this advice, I find that I cannot rely on any verbal recollection of the individuals involved and, therefore, on balance, given the evidence, I find that this advice was not given to Ian.''
In addition, she noted that, although a fully committed rugby player, Ian was clearly an intelligent man who, undoubtedly encouraged by his loved ones, would have paid heed to any advice about his health and future well-being.
The failure to document or record any such advice, if it was ever given, also prompted Mrs Slater to write to the Health Secretary about "sub-optimal record-keeping'' at Doncaster Royal Infirmary, which saw three doctors fail to record details about Ian’s care when he attended hospital in February 2018 (a Regulation 28 - prevention of future deaths) report.
Kashmir Uppal, a partner in Shoosmiths medical negligence team who represented the family, said: “The family’s consistent belief remains that if the essential advice had been provided, Ian would have abstained from physical exertion following his attendance at hospital, and if the GPs and rugby clubs, who were aware of Ian’s cardiac condition, had referred him for cardiology follow-up, the outcome would have been very different.”
Ian’s mother, Pippa Williams, said: “We are grateful to the Assistant Coroner for investigating the events surrounding Ian’s death, and would like to thank our legal team at Shoosmiths for guiding us through the process. Ian was an inspirational and intelligent young man, full of charm and integrity. It is fitting that, through Ian, lives will be saved as awareness of cardiac risk in otherwise fit young athletes is increased. My husband Philip and I are immensely proud of our daughter Helen who is working tirelessly in this regard.”
Ian’s sister, Helen, added: “It is clear that Ian’s death was avoidable if he had been discharged with the appropriate advice. I also want to clarify that an electrocardiogram (ECG) test would not have revealed the true nature of the problem. Had Ian undergone an echocardiogram - or imaging of any kind – he would likely have been put on medication or had surgical intervention and still be with us today.”
Helen continued: “The key for us now is that lessons are learned from this tragedy to prevent similar loss for others. Ian spent his life trying – and usually succeeding - to positively affect those around him, and we want his death to do the same We can take some comfort from the work The Ian Williams Foundation has done with the RFU in positively impacting the sport that Ian loved and hopefully sparing others from the pain of what we have gone through.”
Cardiac screening protocols have now been extended to include additional screening ages, as well as to include the additional professional playing population of the English Championship level from the current 2019-20 season. The family hope that their efforts through The Ian Williams Foundation will continue to further this beyond professional divisions into amateur rugby, and beyond that, into all sports to protect all athletes.
The Ian Williams Foundation: https://theianwilliamsfoundation.org/.
Doncaster Free Press (25 Feb 2020):
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