POLICE are carrying out a further review into the death of a Carlisle businessman in hospital, amid claims from his family about the standard of his medical care.
Nine months after the death of 73-year-old Bill Trotter at the city’s Cumberland Infirmary, his family have still not held his funeral.
His son Mike, 47, and daughter Kelly, 41, say they will continue battling to prove the hospital treatment given to their father was so inadequate that his death should not be attributed to “natural causes.”
They have not held their father’s funeral because they fear this would result in the loss of vital physical evidence. The siblings are challenging a ruling by Cumbria’s senior coroner that there need not be an inquest.
The coroner says a hearing is not justified because Mr Trotter’s death was the result of “natural causes.”
Mr Trotter’s family have already commissioned a post-mortem to support their case but feel so strongly about what happened to their father that they contacted Cumbria Police, asking for the tragedy to be investigated.
They believe his death resulted from a catalogue of errors.
Meanwhile, Mr Trotter’s body remains in “deep freeze” at a facility at Newcastle’s Royal Victoria Hospital. Mike and Kelly contacted The Cumberland News to set out their concerns, including claims that Mr Trotter’s care included multiple misdiagnoses.
Hospital admission
Well known and respected in Carlisle business circles, Mr Trotter was a leading office supplies specialist. In the spring of last year, he was physically well and regularly attending work and out-of-town business meetings.
But he then developed a toe infection which, say his family, was wrongly diagnosed as gangrene.
“It was actually a condition called calciphylaxis, a condition caused by a build up of calcium,” said Mike. That “misdiagnosis” led to what Mike and Kelly say was an “erroneous” decision to amputate Mr Trotter’s leg below the knee.
Following Mr Trotter’s hospital admission on May 8, the amputation was done on June 2 after he was given sedation and nerve-blocking medication.
Mr Trotter then developed a serious urinary tract infection, and it was subsequently discovered that he had been unable to empty his bladder for up to 16 days because no catheter was put in place after his surgery.
When it was installed, it drained 900mls of turbid urine.
“The hospital offered apologies at the time but what happened hampered dad’s recovery,” explained Mike. He and Kelly believes that ‘mistake’ contributed significantly to Mr Trotter developing a serious infection on his backside.
On June 28, this was "misdiagnosed" as Fournier’s gangrene, and the family were told nothing could be done to save Mr Trotter. After they requested a second opinion, Mr Trotter was prescribed an antibiotic.
This led to an improvement.
Timeline
The family provided the following chronology of what they say then happened:
June 8: Despite a scan revealing that Mr Trotter’s bladder was “significantly distended,” no catheter was fitted.
June 16: Concerned that their father was in obvious pain and showing signs of confusion, the family requested a second scan, which reveals the extent of his bladder distention.
June 18: Staff installed a catheter and confirm that Mr Trotter had a urinary tract infection. The family have also confirmed from medical notes show that he was, by this time, suffering from "urinary retention sepsis."
June 30: The Clindamycin antibiotic lightened Mr Trotter darkened skin colour, suggesting the infection was not in fact gangrene. The family say staff were inadequately trained in wound care, or trained in how to properly apply wound care gel or barrier cream.
July 11: A nurse applied wound care gel to Mr Trotter’s posterior wound and his amputation stump, dissolving the stiches – an error for which they say there was no incident report. Kelly says the hospital ran out of wound care gel, triggering her decision to buy some from Amazon to continue her father’s treatment.
July 12: Mr Trotter deteriorated after being given new antibiotic, Tazocin. His family say they were told to say goodbye because it was believed he was “having a heart attack.” There was no heart attack, say Kelly and Mike.
July 15: Family members say they were again called and told of another “heart attack” and told Mr Trotter was dying. The family suspect he was reacting to the new antibiotic. His condition improved once Tazocin was stopped.
July 16: Mr Trotter, who was diabetic, was given a 10-unit dose of long-lasting insulin, allegedly administered without the prior knowledge of or input from the hospital diabetes team, which the family believe put Mr Trotter into a coma. They say this was “a dangerously inappropriate intervention.”
July 17: The family allege that one of the doctors involved in Mr Trotter’s care told them that he believed Mr Trotters leg need not have been removed.
July 18: Mr Trotter died.
"We believe the failure to fit a catheter after the amputation had ‘a snowball effect’ on our dad’s health," said Mike.
"The urinary tract infection he then developed ravaged his body. We firmly believe the sepsis our dad developed was caused by the failure to fit a catheter.”
He and Kelly also believe that the administration of long-lasting insulin, without the guidance of the diabetes team, led to Mr Trotter – already weakened by infection - falling into the coma from which he never emerged.
Their father’s blood sugar levels in the hours before his death were within a “normal healthy range,” thus making the insulin injection not medically justified, they say.
Inquest decision challenged
The family’s lawyer has now written to the area’s senior coroner on their behalf, challenging the refusal to hold an inquest and the assessment that Mr Trotter’s death was down to “natural causes”.
“What we have seen in that hospital was scary,” said Kelly.
She and Mike (pictured below) recalled occasions when they found their father was not being given adequate personal care, increasing the risk of infection.
Their father also repeatedly asked them to get him out of the hospital, but staff would not allow it, they say.
Kelly added: “There were no incident reports raised by the hospital over the three mistakes with dad’s care - what happened with the catheter, the wound care issue, and the insulin administration.
“I raised that last issue with the diabetes team.
“Our dad was a fighter, a loving father who always put his family and everybody else first. We felt we could not let what happen to him go unchallenged. We want an inquest because we want to get to the truth.”
'Review is ongoing'
A spokesman for Cumbria Police said: “The death of Mr Trotter was investigated, which included assessment of the findings from a full postmortem examination, and the family were subsequently informed that no criminal proceedings would be taken.
“After additional information has recently been provided, Cumbria Police is currently carrying out a further review. This review is ongoing, and it would not be appropriate to comment further at this stage.”
In March, Coroner Kirsty Gomersal wrote to the Mike and Kelly saying that Mr Trotter’s case did not meet “statutory criteria” that would require an investigation by the coroner because his death was down to “natural causes.”
She said the hospital’s Lead Medical Examiner had reviewed the case and reached the same conclusion. The coroner also asked her colleague Dr Nicholas Shaw, a medical practitioner with 45 years’ experience to consider the case.
He had also concluded that there were no “relevant acts or omissions in relation to his care” that would justify an inquest.
A spokesperson for North Cumbria Integrated Care NHS Foundation Trust, which manages the Cumberland Infirmary, said: "We would like to extend our deepest sympathies to the family of Mr Trotter at what is a very upsetting and traumatic time.
"The family’s complaint into the care of their father is ongoing and we are in the process of arranging a further meeting with them to discuss this directly. It would therefore be inappropriate to comment at this time."
