Medics miss several chances to save man’s life

Dr Kevin Lee
Dr Kevin Lee

HEALTH bosses have launched an investigation after a well-known Doncaster GP failed to spot a man had suffered a heart attack days before he died.

Dr Kevin Lee instead prescribed the man, who was complaining of shooting pains in his chest and arms as well as breathlessness, anti-biotics for a chesty cough, an inquest heard.

The GP also failed to carry out checks for blood pressure and a pulse during the ten minute examination, the hearing was told.

Dean Beresford, 44, who had also consulted other medics over his symptoms died after collapsing.

Coroner Stuart Fisher said there were four “missed opportunities” to get Mr Beresford, of Gainsborough, emergency treatment.

Following the hearing a spokesman for Doncaster Primary Care Trust, confirmed Dr Lee was a GP at The Scott Practice in Balby, and health bosses would be looking at the coroner’s findings.

He added Dr Lee had kept the trust “fully informed through the process.”

Rose Fells, managing partner of The Scott Practice, said: “Dr Lee would like to offer his condolences to the family of Mr Beresford. He is unable to comment further due to patient confidentiality.”

The hearing heard how Mr Beresford’s partner Tina Coupland, with whom he had a daughter Isobella, now four, said he called NHS Direct’s helpline on July 31, 2010 because he was feeling unwell.

However, despite experts telling the hearing that the symptoms that Mr Beresford gave were heart related and warranted a 999 call, an NHS Direct advisor did not log his symptoms as chest pain.

That error filtered into the assessments of three other health professionals, causing a misdiagnosis, including from nurse advisor Beatrice Makonyola who said Mr Beresford, of Gainsborough, had a chest infection.

The lorry driver was referred to Dr Richard Smith, an out-of-hours GP based at Lincoln County Hospital, who then booked an immediate appointment with Dr Lee, who was also working at John Coupland Hospital in Gainsborough.

Mr Beresford collapsed in a toilet cubicle 11 days later and died at Lincoln County Hospital on August 11, 2010.

Tricia Hamilton, NHS Direct’s clinical director, admitted it was a very serious failure.

Recording a narrative verdict, the coroner said “I am satisfied NHS Direct have taken this matter very seriously.

“There is a clear recognition by NHS Direct and Lincolnshire Health Trust that there have been serious failings on both of their parts.”