Man’s death in hospital was ‘avoidable’, inquest hears

A picture of John Brackenbury released by his family, who say he was let down by the system. Picture

A picture of John Brackenbury released by his family, who say he was let down by the system. Picture: CONTRIBUTED - Credit: Archant

An inquest has heard that an “independent and active” grandfather from Thetford died after a life-saving brain operation was cancelled and another patient was prioritised ahead of him.

Salesman John Brackenbury, 70, of Thetford, had suffered a brain bleed and was awaiting surgery at Addenbrooke’s Hospital, Cambridge, in December last year.

The inquest at Norfolk’s Coroner’s Court heard from a Dr Yogish Joshi, who said that the urgency of Mr Brackenbury’s care was “lost in communication” and so prioritised someone else who had recently bled ahead of him.

Mr Brackenbury died in hospital that same night, December 2, 2016.

Consultant neuro-radiologist Dr Joshi said in evidence it was likely Mr Brackenbury would have survived if he had had the operation.


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Norfolk’s area coroner Yvonne Blake said she had heard credible evidence of work to improve communications between teams at the hospital.

Ms Blake also said she accepted there was a lack of neuro-radiology cover at Addenbrooke’s on November 30, 2016, the day after Mr Brackenbury was admitted, but this was an individual failing and not a systemic one.

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She said his treatment was not grossly neglectful.

Recording a narrative conclusion, Ms Blake said: “Mr Brackenbury died of a cerebral haemorrhage while awaiting specialist treatment.”

Mr Brackenbury’s family described him as a “very independent and active 70-year-old” and said his only previous visit to hospital was for a broken arm.

In a statement released after the inquest, members of Mr Brackenbury’s family said: “John was a devoted husband and father and his passing has left a huge hole in all of our lives.

“The nature of how he died and the suffering he endured haunts us all.

“Indeed, what is most tragic is that his loss was so avoidable.”

Tim Deeming, a specialist medical negligence lawyer from Slater and Gordon, which represents the family, said: “Unfortunately, apparent failings led to his unnecessary and avoidable death given that treatment was not prioritised to comply with the national guidelines.”

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