A father from Devon was able to disconnect his oxygen and leave his bed before collapsing in a corridor. He was found dead by a porter at the Royal Devon and Exeter Hospital.
The coroner at the inquest into Calvin Marchant's death found "there were a number of errors, omissions and oversights that contributed to his death.”
The 48 year old was admitted with acute pancreatitis and died from cardio respiratory failure, vomiting, and pneumonia which developed in the days before his death.
The coroner ruled there was:
an absence of a weekend management plan
failure to allocate him a correct consultant
an absence of further clinical examination and review.
She also said that if Calvin had been examined in the last few hours of his life there would have been clear signs for sepsis.
There were enough nurses. He was in the right place. But one to one nursing was not utilised. Despite a black alert Mr Marchant was not under pressure to be discharged early or inappropriately and was in the right place ‘notwithstanding the hospital’s difficulties.
His family say they knew something was seriously wrong.
We cannot accept claims by hospital staff that Calvin appeared to be coherent and doing well during his final days. When we spoke with him we found him to be very confused and unable to hold a conversation – his desperate phone calls to his family, and even to the police, showed that something was clearly very wrong. >
The Trust would like to publicly express its condolences to Mr Marchant’s family for their loss.