1. ITV Report

Bath University student's death contributed to by 'neglect' of hospital staff

22-year-old Alex Green suffered a respiratory arrest 10 hours after being admitted to hospital. Credit: Avon and Somerset Police

The death of a student from the University of Bath was "contributed to by neglect" from hospital staff, a coroner has found.

22-year-old Alex Green died from serious head injuries days after he was found unconscious at a bus stop in Bath city centre on 30 September 2017.

An inquest concluded a number of hospital staff failures "caused or significantly contributed to Alex's death".

Maria Voisin, senior coroner for Avon, said: "There was an assumption by everyone managing Alex that he had been intoxicated when in fact, he had a significant head injury".

Ms Voisin identified five failings with Alex's care, including the fact he wasn't seen by a doctor for three hours despite having a reduced Glasgow Coma Scale (GCS) score.

The GCS is a way of assessing someone's state of consciousness. Ms Voisin said the staff assumption that Alex's reduced consciousness was due to intoxication came with "no corroborating evidence".

The conquest concluded hospital staff made several failings which contributed to Alex's death. Credit: ITV West Country

The economics student from Surrey was on a night out to celebrate his birthday on 29 September 2017.

CCTV from The Second Bridge nightclub showed Alex picking up a female friend at around 2:42am and both of them falling over. Alex is then seen holding the back of his head.

He was later found unconscious by a group of five students at 3:48am and taken by an ambulance to the Royal United Hospital just under an hour later.

A paramedic concluded the student's condition was due to alcohol, which was shared by a doctor who examined him again a few hours later.

The inquest also heard Alex fell from his hospital bed at around 9am but wasn't examined. He was then transferred to an observation ward.

Ms Voisin said there was a "gross failure to provide basic medical attention which Alex obviously needed".

At 1:45pm a nurse heard "gurgling noises" from Alex and turned him on his side, and just 20 minutes later he was noted to be in respiratory arrest.

The results of a CT scan revealed his head injury and he was taken to Bristol's Southmead Hospital for surgery.

Ms Voisin said the "delay in diagnosis and transfer" meant Alex's treatment was "futile".

He died three days later.

CCTV footage shows Alex walking from the city centre just minutes before he was found unconscious. Credit: Avon and Somerset Police

The five-day inquest concluded Alex should have undergone neurological tests after arriving at the Royal United Hospital and questions should have been asked as to why he wasn't regaining consciousness.

Neurosurgeon James Palmer told the hearing Alex's life could have been saved if a CT scan had been carried out earlier.

According to the coroner he said "a transfer any time before 11:15am would have led to a good outcome".

Alex's parents said after the hearing their son was "wonderful, bright, beautiful and kind."

Our grief is overwhelmingly painful every day. As a family, we are shocked and appalled by the lack of care given to Alex by both the South West Ambulance Service and the Royal United Hospital. Alex was in their care for over 10 hours, with a serious but detectable and treatable head injury which was not properly considered and never diagnosed.

– Alex Green's parents
This is one of the last images captured of Alex before he was found by a group of students. Credit: Avon and Somerset Police

The Royal United Hospitals Bath NHS Foundation Trust, which was criticised for failing to diagnose a "spectacular" internal head injury, said it extended "sincere sympathy and apologies" to Alex's family and friends.

Following this tragic incident in 2017, we carried out an investigation and shared the findings with Alex's family and the coroner. We will now reflect on the coroner's findings and act on the further learning opportunities identified.

– Bernie Marden, medical director for The Royal United Hospitals Bath NHS Foundation Trust

The full list of failings identified:

  • On Alex's arrival at the hospital, there was an assumption that his reduced consciousness was due to alcohol intoxication despite no corroborating evidence.
  • He had a reduced Glasgow Coma Scale (GCS) for three hours before being seen by a doctor.
  • He should have been managed in line with the hospital's falls policy after falling off his hospital bed.
  • He should have been seen and examined by a doctor before he was transferred to the observation unit.
  • His GCS was never normal, but was not acted upon.