NHS delays led to man’s overdose death, SOP overhaul follows

An inquest has revealed that a series of “mistakes and delays” by the NHS’s A&E unit contributed to the overdose death of Kenneth Metcalfe, 63, on October 14 2022. Kenneth, who had overdosed on his prescription medication, had his chances of survival significantly reduced due to these errors.

Durham and Darlington Coroner Crispin Oliver noted that although prompt treatment wouldn’t have prevented Kenneth’s death, there was a clear pattern of mistakes and delays.

Kenneth’s overdose occurred a day before his death, and the coroner agreed with Kenneth’s grandfather that it was a “cry for help” rather than a deliberate attempt on his life. Kenneth had been concerned that his broken mobile phone would hinder his access to drug and alcohol support services.

The coroner concluded that Kenneth died from ketoacidosis following the overdose of prescription medication. It was determined that on the morning of 13 October, Kenneth had consumed six days’ worth of his prescribed medication.

Kenneth’s family expressed their heartbreak and outrage over the incident, hoping that no one else would have to endure a similar ordeal. His daughter Donna described the distress the family felt upon discovering Kenneth’s deteriorating condition on October 14.

She paid tribute to her father, recalling how he raised the family single-handedly while holding three jobs and battling depression.

Kenneth Metcalfe, 63, died on October 14 2022 following an overdose of prescription medication – an inquest heard how there had been a ‘series of mistakes and delays’ in his care https://t.co/iuMRxWLHg3

— Teesside Live (@TeessideLive) September 27, 2024

Donna criticised the medical response, stating that blood tests should have been conducted immediately. On October 13, a family member found Kenneth seriously unwell after he had taken the overdose. An ambulance was called, and the first crew was dispatched at 3.36pm, arriving at 3.39pm and recording initial observations at 3.46pm. Kenneth was taken to the University Hospital of North Durham at 4.34pm, arriving at 5.15pm.

However, he remained in a hospital corridor for over three hours before being handed over to A&E staff after 9pm. Blood test results, phoned in at 11.17pm, were not acted upon due to issues with the hospital’s electronic patient record system.

Kenneth needed intravenous fluids by 11.30pm but did not receive them until 5.30am the following day.

Expert witness Doctor Neil Langford testified that Kenneth’s care was substandard and reduced his chances of survival. Despite the shortcomings, Dr Langford concluded that Kenneth’s death was not preventable, even if treatment had been administered quicker.

Dr Langford also mentioned that while paramedics should have considered giving Kenneth activated charcoal, their decision not to was not unreasonable at the time. Both the County Durham and Darlington NHS Trust and the North East Ambulance Service have issued apologies to Kenneth’s family.

NEAS Chief Executive Helen Ray acknowledged serious errors in Kenneth’s care, admitting that the initial ambulance crew failed to recognise the severity of his condition and spent too long on the scene.

The NHS Trust, which oversees the University Hospital of North Durham and Darlington Memorial Hospital, admitted multiple failings and outlined steps taken to prevent future occurrences. These measures include enhanced training sessions, new Standard Operating Procedures (SOPs), and an audit programme to ensure ongoing improvements in patient safety and care.

A spokesperson for the Trust extended their deepest condolences to Kenneth’s family, emphasising their commitment to learning from the incident and improving patient care standards.