A grandfather died waiting for a life-saving brain operation after another patient was prioritised over him, an inquest heard.
John Brackenbury, 70, suffered a severe bleed on the brain and needed surgery which usually treats the condition in just 48 hours.
But the procedure to place a metal coil in the aneurysm so it cannot fill with blood was postponed and he died after the bleed worsened.
Consultant neuro-radiologist Dr Yogish Joshi told the inquest into his death that Mr Brackenbury, of Thetford, Norfolk, was likely to have survived had he been operated on earlier.
John Brackenbury, 70, died waiting for a life-saving brain operation after another patient was prioritised over him, an inquest heard
He told the inquest at Norfolk Coroners; Court that the urgency of Mr Brackenbury’s case may have been ‘lost in communication’.
Norfolk Area Coroner, Yvonne Blake, concluded his death was ‘an individual rather than systematic failure’.
In a statement made by his family, Mr Brackenbury was described as a ‘very independent and active 70-year-old’.
The family added: ‘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.’
The inquest heard Mr Brackenbury’s family were concerned by the lack of communication by hospital staff.
‘He was overseen by multiple medical and nursing professionals and we promised him that he would be looked after within their care.
‘Sadly he seems to have been let down from start to finish. We were all immensely proud of the NHS before this and his daughter Jenny is a nurse.
Mr Brackenbury suffered a severe bleed on the brain and needed surgery which usually treats the condition. But his procedure was delayed after another patient was prioritised over him
‘Now even she is questioning her own career for an organisation that allowed this to happen to her father.’
The inquest heard how Mr Brackenbury attended Queen Elizabeth Hospital (QEH) in King’s Lynn, Norfolk, on November 18, 2016, after experiencing ‘crushing’ headaches.
He was referred to Addenbrooke’s hospital after collapsing on November 29 after suffering a cerebral bleed.
An appointment was made for him to undergo brain surgery days later on December 1, 2016, but he died on December 2.
Dr Yogish Joshi, consultant neuro-radiologist at Addenbrooke’s, told the inquest that the highest risk of a further bleed is within 24 hours of a haemorrhage.
He said the risk ‘gradually diminishes after that’ and if multiple patients need an operation they try to prioritise patients at greatest risk.
The inquest heard how Mr Brackenbury attended Queen Elizabeth Hospital (pictured) in King’s Lynn, Norfolk, on November 18, 2016, after experiencing ‘crushing’ headaches
But Dr Joshi said Mr Brackenbury’s operation was cancelled as doctors mistakenly believed he suffered a haemorrhage at the QEH, weeks before being admitted to Addenbrooke’s, and so another patient was prioritised.
However, consultant neurosurgeon Rikin Trivedi told the inquest it was ‘inconceivable’ that the doctors would not have been made aware of the recent bleed, adding: ‘It is never not clear.’
Norfolk coroner Yvonne Blake found the evidence from Dr Joshi ‘vague and unconvincing’, adding ‘in particular that he had or did not remember the dates on the scans he viewed.’
When looking at whether the hospital had been neglectful, Ms Blake said: ‘He [Mr Brackenbury] had been diagnosed promptly with an aneurysm which needed specialist treatment for which he was waiting.
‘It cannot therefore, in my opinion, be proper to say that the clinicians/hospital were grossly neglectful in his treatment.’
He was referred to Addenbrooke’s hospital (pictured) after collapsing on November 29 after suffering a cerebral bleed. He died on December 2
The medical cause of death was given as subarachnoid haemorrhage due to ruptured intracranial aneurysm.
Delivering a narrative conclusion, Ms Blake said Mr Brackenbury, died of a cerebral haemorrhage whilst awaiting specialist treatment.
Tim Deeming, a specialist medical negligence lawyer from Slater and Gordon, which represents the family, said: ‘Mr Brackenbury was still working and hardly had a day sick in his life.
‘Unfortunately an apparent catalogue of failings led to his unnecessary and avoidable death given that his treatment was not prioritised to comply with the national guidelines.
‘We hope lessons can be learned from the failings in this tragic case across the NHS to ensure that improvements are made.’