Student 'likely to have lived' if seen in-person by GP, coroner rules

A law student who died after four remote GP appointments was likely to have lived if he had been seen face-to-face, a coroner has ruled.

David Nash died in November 2020 after developing mastoiditis in his ear, which caused an abscess on his brain.

Mr Nash, 26, spoke to a GP practice in Leeds four times during a 19-day period, but was not seen in person.

Coroner Abigail Combes said the failure to see him meant he underwent surgery a crucial 10 hours later than it could have been.

She said the failure to arrange an in-person examination when he complained to an advanced nurse practitioner of fever, neck stiffness and nighttime headaches in the days before his death was a "missed opportunity."

Recording a narrative verdict after an inquest at Wakefield Coroner's Court, Ms Combes said: "On 2 November 2020 there was a missed opportunity to direct David to seek face-to-face care during his GP appointment that morning.

"Had he been directed to seek face-to-face or urgent care by the GP practice it is more likely than not that he would have undergone neurosurgery approximately 10 hours earlier than he actually did which, at that time, it is more likely than not would have been successful."

Mr Nash's parents, Andrew and Anne, said they were "both saddened and vindicated by the findings that the simple and obvious, necessary step of seeing him in-person would have saved his life".

Reading a statement outside court, his mother said: "As a family, we have been devastated by David's death. He was our wonderful son, brother and friend."

She said the family had spent two years trying to "make sure others don't die as David did.”

During the week-long inquest Ms Combes read a statement from GP expert Alastair Bint, who said a nurse should have organised an urgent in-patient appointment after the phone consultation on 2 November.

Dr Bint said he did not criticise the remote nature of Mr Nash's first three consultations in October 2022 by Burley Park Medical Centre.

However, he said he thought a face-to-face appointment would have led to the advanced nurse practitioner, who spoke with Mr Nash, admitting him to hospital.

A neurosurgeon, Simon Howarth, told the inquest he thought surgery 10 hours earlier would have avoided Mr Nash's death.

Record of David Nash’s calls to Burley Park Medical Centre

• 14 October: Mr Nash called concerning lumps on his neck.
• 23 October: Calls and tells an advanced nurse practitioner about a painful and hot right ear
• 28 October: Tells locum GP he has blood in his urine and is diagnosed with a urinary tract infection
• 2 November: Diagnosed with flu-like viral infection after phone call with another advanced nurse practitioner
• 2 November: Mr Nash and his partner make five calls to NHS 111 when his condition deteriorates. Later he is taken to St James's Hospital before being transferred to Leeds General Infirmary for neurosurgery
• 4 November: Mr Nash dies in hospital.

Harrowells partner in the firm’s Catastrophic Injury and Clinical Negligence team, Kim Daniells, says: “In this case the GP expert seems to have identified one particular call where the decision-making was poor. David Nash had a series of health issues in a short space of time that he had tried to communicate to different individuals at the GP practice, remotely.  Some or all of those different symptoms could have been connected to the underlying condition. 

"In this very sad case it seems that the effects of the pandemic, the multiplicity of clinicians, the lack of face-to-face assessments, and poor decision-making of the nurse practitioner all conspired to lead to this tragic outcome.