Failure in care leads to hospital changes

A COLLAPSED lung sustained by a 22-year-old car crash victim went undiagnosed until just moments before he was due to undergo a major operation.

Laurence Cawley

A COLLAPSED lung sustained by a 22-year-old car crash victim went undiagnosed until just moments before he was due to undergo a major operation.

James Leeks, of Newton Green, near Sudbury, died at Colchester General Hospital on September 3, 2006, after the MGF sports car he was driving collided head-on with a Skoda outside the Wyevale garden centre on the outskirts of Sudbury on the A134 four weeks earlier.

He was airlifted to hospital with multiple injuries including a broken wrist, a broken tibia and a fractured femur.

An inquest into his death held yesterday in Bury St Edmunds heard Mr Leeks, once ranked the third best tennis player in the country, died of acute respiratory distress syndrome (ARDS), a thickening of the lungs in response to a trauma.

Mr Leeks family claim this was among a number of mistakes made by the hospital during his treatment.

Most Read

But it also emerged how Mr Leeks had suffered a collapsed lung which was only picked up by an anaesthetist immediately prior to an operation to set a broken leg - the day after he was brought into hospital.

Although an x-ray of his chest had been carried out, the inquest heard, the collapsed lung was not spotted immediately by doctors.

Casualty consultant Dr Sanjay Patel, who was not involved in Mr Leeks' case, said the x-ray had been “misread”.

Giving evidence, consultant orthopaedic surgeon Mr Jeremy Parker told how Mr Leeks was “not seen overnight” by doctors when he was transferred from intensive care to the orthopaedic West Bergholt ward prior to surgery.

Mr Parker said the collapsed lung might have been a problem had he gone into surgery as planned, though it did not have an impact on the ARDS condition which eventually killed him.

During the hearing, the hospital revealed it had taken numerous steps to improve its information systems and dealings with trauma victims following Mr Leeks' case.

Senior hospital manager Anne Morris said in the wake of Mr Leeks' death a new trauma delivery room had been set up, documentation had been improved, better systems put in place for managing case notes and more regular auditing of all documentation introduced.

Suffolk Coroner Dr Peter Dean said there had been a “gap in the care during which there was a problem” when the 22-year-old was moved from accident and emergency to the orthopaedic ward.

He said although the collapsed lung was “easy to miss”, “what seems much more difficult to understand was why the possibility that he may then develop further chest problems wasn't then passed on to the ward that took care of him”.

“There was a failure to hand over information,” said Dr Dean. “There were clearly issues in information handover and monitoring. These issues have clearly been recognised by the hospital and steps have been taken to make significant changes.”

Dr Dean recorded a narrative verdict that Mr Leeks died of complications as a result of a road traffic accident.

Speaking following the inquest, the family of Mr Leeks claim he did not get “adequate care and attention” during his four weeks in hospital.

In a statement from the family, his mother Judy Leeks said: “We appreciate that emotions run high whilst dealing with such a tragedy.

“If procedures had been followed properly,” said Mrs Leeks, “maybe the problems with his chest would have been recognised earlier.

“We will always maintain that Jim did not receive the level of adequate care and attention needed for his serious and unstable condition. Nothing will ever bring Jim back and the only thing that can come out of this now is improvement for other people's care.”

During the inquest, medical experts from Colchester University Hospital Trust admitted a number of difficulties emerged during Mr Leeks' time at the hospital.

These included the misreading of a chest x-ray, the removal of a neck collar before spinal injury could categorically be ruled out and late diagnosis of Mr Leeks' collapsed lung.

As a result, the trust carried out an investigation into Mr Leeks' care and a number of recommendations for tightening up procedures have been introduced.