Questions have been raised over the treatment of a Wigan man killed by a rare vascular condition which doctors mistook for a stroke.
Both Wigan and Salford NHS Trusts came under fire during the inquest into the death of popular Aspull rugby player and IT analyst Christian Walsh.
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The 34-year-old was misdiagnosed has having suffered a stroke when in fact he had an almost undetectable tear in his main artery.
He died just days after falling ill last April.
Coroner John Pollard said that although Christian received “inadequate” care from both hospitals, the mistakes were not such to have contributed to his death.
Christian, who was engaged at the time of his death, was taken to Wigan Infirmary by ambulance in April last year after complaining of dizziness, weakness in his legs and a ‘strange’ sensation in his throat.
On arrival, doctors - who initially suspected a stroke due to the limb weakness - sent him straight to Salford Royal Hospital without carrying out any scans on his brain.
The decision, which is in line with the stroke pathway devised by Greater Manchester health chiefs, saw Mr Walsh- who had been diagnosed with high blood pressure three years previously - shuttled back and forth between Salford and Wigan, where he died three days later.
An inquest at Bolton Coroner’s Court heard how multiple failings at both Wigan and Salford left the popular Aspull RU stalwart receiving ‘suboptimal’ care, but that this did not contribute to his death.
Coroner John Pollard raised questions about the efficacy of the stroke pathway, which sees Wigan patients sent straight to Salford Royal Infirmary when they are suffering from a suspected stroke, without any scans being carried out first.
Mr Pollard heard how Mr Walsh had been at Aspull RU Club, where he was secretary, when he began complaining that he did not feel right.
The well-known sportsman, who also had strong ties to Aspull JuniorFootball, was walking to speak to St John Ambulance staff at the ground when he collapsed.
Emergency services were called and he was rushed to hospital complaining of “severe lower back pain”.
Shortly after arriving at Wigan, he was sent straight to Salford with doctors suspecting he had suffered a stroke.
However once there, Christian’s family were told that it was unclear why he had been sent to Salford Royal as he was clearly not having a stroke.
Doctors told staff to put him on pain medication and send him back to Wigan and that he should be released home if the painkillers worked.
Speaking at the inquest, Christian’s mum Marie Walsh, said: “No one actually looked at him as a person. It was ‘he’s had a stroke, no, he’s not had a stroke - he’s not our responsibility.
“Give him painkillers and get him back.”
During the hearing, it also transpired that senior practitioners at Salford Royal had failed to document any notes about Mr Walsh’s case.
Dr Jane Molloy, consultant neurologist and registrar Dr Arrabella Hamilton were questioned by Mr Pollard, who said: “You didn’t make a note of that examination. That is pretty poor practice.”
The inquiry then heard how Mr Walsh was transferred back to Wigan Infirmary in the early hours of April 1, with a “working diagnosis” of sciatica.
After being assessed, he was booked in for an MRI scan, but this was not able to take place until the Tuesday because it was a Bank Holiday weekend.
Consultant radiologist Dr Ahmed Ismail was also quizzed by Mr Pollard, who expressed concern that no other scans were carried out to get to the root of Christian’s pain and no vascular examination took place despite his history with hypertension.
He asked the consultant of 21 years why no other tests were conducted and was told that he was advised by the acute medical consultant that Mr Walsh had suspected sciatica - and that is what he was investigating.
Mr Pollard added: “Do you think you asked enough questions about Mr Walsh? It seems to me that you reached a conclusion without making any inquiries of your own. You simply accepted what your colleague said.”
However, Dr Ismail said that radiologists regularly accept information passed over to them without asking questions of the consultants, a practice which he said could be interpreted as “rude”.
“It’s my duty to accept his decision,” said Dr Ismail.
Mr Pollard added: “It is your duty as a doctor to make a full and proper diagnosis.”
The inquest heard how Mr Walsh stayed in hospital on April 1 and 2, undergoing numerous tests to find if there was an infection. The pain in his lower back and legs continued and also spread to his abdomen.
Mr Pollard found that at no point was the MRI carried out because the machine is not staffed during weekends or Bank Holidays.
In the early hours of April 3, Mr Walsh was found unresponsive in his hospital bed. Despite resuscitation attempts, he was pronounced dead shortly after.
A post-mortem examination found that he had died from a dissecting aortic aneurysm, a condition where the lining of the aorta tears and bleeding occurs within the walls of the artery.
All of the clinicians agreed that his symptoms were “atypical” of the condition, with most of them agreeing that they had only seen a handful of cases throughout their career - mostly in elderly people with severe chest or abdominal pain.
The coroner agreed that the condition would not have been found through an MRI scan and may only have been picked up if a CT to his abdomen was carried out.
He said: “Christian’s presentation was atypical of an extremely rare condition. It was rare but completely naturally occurring, it wasn’t something he had done to himself.
“There are number of instances of inadequate care and suboptimal care but none of these was such as to alter the inevitable conclusion that he died of natural causes.”