Wednesday, January 18, 2017

Air ambulance doctor killed himself after learning his drug blunder led to death of dad-of-four

Air ambulance doctor Carl McQueen took his own life after giving Mr. Hanstock a fatal drug dose, an inquest heard. 

A tormented air ambulance doctor killed himself after learning his drug blunder contributed to the death of a dad-of-four, an inquest heard.

Dr. Carl McQueen, a father-of-two, was devastated when Lee Hanstock died after he was given a fatal double dose of sedative.

Lee, 43, who worked at Aston Martin, had a history of good health and had not seen a GP for 15 years.

He was taken ill with high blood pressure in December 2015 and routine checks were not carried out, vital signs were missed, and he was sent home from hospital too soon without medication.

Lee was suffering from acute hypertension, a rare condition where a person’s blood pressure becomes so high it can cause permanent organ and brain damage.

“Multiple missed opportunities” at a hospital meant his serious conditions were not identified and he was discharged prematurely, an inquest at Burton-upon-Trent, Staffs, heard.

When his desperate family later called for an ambulance he was mistakenly given a double dose of a drug meant to help him.

The dose was one of several “significant failings” that contributed to Mr Hanstock’s death.

Dr. McQueen, who had administered the sedative, later killed himself in the garage of his grandfather’s house.

A coroner ruled yesterday that Lee’s death would have been prevented had he been given “suitable treatment”.

Lee started feeling unwell just after Christmas 2015 and suffered from severe migraines, nausea, and was vomiting 15 times in a day.

He travelled with his wife Amy Tipper to the Cross Street Surgery in Burton-upon-Trent on December 28 where he waited for two hours before being seen.

After the doctor realised he was suffering from acute hypertension he was sent to the Accident and Emergency Department at Queen’s Hospital in Burton.

When he arrived he had “remarkably high” blood pressure and was given a series of treatments to attempt to bring it under control.

When Lee, from Barton-under-Needwood, Staffs, first arrived at hospital, he was not given an ECG, which could have saved his life, the inquest heard.

He was then sent home despite his wife questioning the results of a CT scan, which she was told “looked fine”.

Staff were aware that Lee was suffering from hypertension and he was discharged without medication to deal with the problem.

He was simply told to contact his GP about his migraine.

Six hours after being admitted to hospital he was back at home.

Less than 24 hours later he was dead.

Dr. Tarunya Vedulta, one of the team of people responsible for discharging Mr Hanstock, was in tears as she told the inquest she thought that the symptoms could have been dealt with at home.

She said: “We saw that he had long-standing hypertension, which I thought were being exacerbated by his migraine and a chest infection. He was responding to treatment, and I thought those symptoms would continue to get better when he left hospital.”

Asked if she saw ECG results, she said: “I thought I saw an ECG. I honestly did. All the paperwork tends to be loose so it could have been someone else’s. It’s all loose.”

Lee suffered a seizure at his home 24 hours later and his family dialled 999.

When ambulance crews arrived Dr McQueen gave him an injection of 500mg thiopentone to sedate him so he could be safely moved downstairs to take him to hospital.

A suitable dose would have been ‘250 or 300mg’.

The drug caused his blood pressure to drop rapidly, which was not picked up on quickly enough by the crew, and he went into cardiac arrest.

Dr. McQueen committed suicide on February 12 last year after learning that the ambulance service were investigating the incident.

The inquest heard how Dr. McQueen’s wife, Kirsty, a former nurse, and their two children lived in Nottinghamshire, while he stayed at his grandfather’s house in Solihull, West Mids.

He was juggling shifts at the Midlands Air Ambulance at Cosford with doing his Phd at Warwick University and also doing locum work as an emergency doctor in Derby.

Magnus Harrison, the Burton Hospital NHS Trust’s executive medical director, led the serious case review into what happened to Mr Hanstock.

He said rigid procedures had been put in place to ensure that lessons were learned.

Mr Hanstock’s family lawyer Dr Peter Ellis said: “This is an unusual case in the sense that there were multiple opportunities to do things in Lee’s case.

“There was a failure to perform an ECG, a failure to see the significance of the CT scan, the missed opportunity to seek senior review about the premature discharge when his blood pressure was still very high and he remained confused.

“In addition to that, there’s the excessive dose of thiopentone and a failure to recognise the hypertension that resulted from that.”

Giving a narrative conclusion South Staffordshire Coroner Andrew Haigh said “This is a natural death but there have been a number of significant failings.”

He recorded a cause of death as “natural causes, where the death could have been avoided through suitable treatment.”

But he said he was satisfied the hospital had learned from the robust action plan which now exists.

After the hearing Lee’s wife Amy Tipper said: “Lee was a wonderful caring father, son and partner, with a big personality who filled our lives with love, laughter and fun.

“It is devastating to know that his death was avoidable, and that had appropriate treatment been provided our family would still be complete.”

Joe Tipper, Amy’s brother, said: “It has been difficult for Amy, Lee’s parents and family to come to terms with what happened, especially given the time of year.

“The actions of Dr McQueen, for whose family we have nothing but the greatest sympathy for their equally tragic loss, were well-documented.

“However, what makes our loss even harder to bear is the knowledge that it could have been prevented at a much earlier stage.”

A West Midlands Ambulance Service spokesman said: “The Trust apologised to the family of Mr Hanstock following his death in 2015.

“The coroner concluded that Mr Hanstocks death was due to ‘natural causes’ but noted that there were several failures in his care by the NHS which contributed to his death.

“A serious untoward incident was raised by West Midlands Ambulance Service at the time and an extensive internal investigation was carried out. The Trust has since taken appropriate steps to ensure a similar incident is not repeated.

“Our thoughts remain with the family of Mr Hanstock and we offer our sincere condolences to them.”

Burton’s Queen’s Hospital declined to comment.

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