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Switchboard operator weeps as she admits sending crash workforce fallacious method

A hospital switchboard operator wept today as she admitted sending a resuscitation team to the wrong location after a retired engineer collapsed following a routine CT scan.

Bowel cancer survivor David Horsman, 65, had previously experienced ‘no reaction whatsoever’ while undergoing annual scans, his widow Jane told an inquest.

In March 2022 he was invited to a mobile scanning unit in the car park of Royal Bolton Hospital, operated by a private firm as part of efforts to tackle post-Covid backlogs.

But the ‘proud grandad’ – an internationally-renowned expert in overhead power networks – went into anaphylactic shock after being injected with contrast dye used to highlight organs during the scan.

An inquest into his death has heard there was a breakdown in communication between the radiographer who tried to raise the alarm and the hospital switchboard operator.

Retired engineer David Horsman, 65, died following a routine scan following a 17-minute delay at Royal Bolton Hospital, an inquest has been told

Retired engineer David Horsman, 65, died following a routine scan following a 17-minute delay at Royal Bolton Hospital, an inquest has been told

The inquest heard there was a breakdown in communication between the radiographer Idongesit Okon (pictured) who tried to raise the alarm and the hospital switchboard operator

The inquest heard there was a breakdown in communication between the radiographer Idongesit Okon (pictured) who tried to raise the alarm and the hospital switchboard operator 

David Horsman had been invited in March 2022 to a mobile scanning unit at Royal Bolton Hospital (pictured) operated by a private firm as part of efforts to tackle post-Covid backlogs

David Horsman had been invited in March 2022 to a mobile scanning unit at Royal Bolton Hospital (pictured) operated by a private firm as part of efforts to tackle post-Covid backlogs

Anne Parker mistakenly sent the ‘crash team’ to the children’s ward, leading to a 17-minute delay until they finally located the unit, by which time Mr Horsman’s heart had stopped.

The keen gundog trainer was placed in an induced coma but died the following day after suffering multiple organ failure.

In recordings played to the hearing, Ms Parker told an ambulance handler that radiographer Idongesit Okon – who had flown in from Nigeria weeks earlier – ‘didn’t speak much English’.

But giving evidence today, she admitted she had been the one who caused the ‘confusion’ by asking him if he was at the children’s ward – something he tried to clear up in a third call.

The mix-up happened because the unit’s details were still on her phone screen when the crash call request came in, Ms Parker claimed.

Coroner John Pollard suggested it had been ‘quite clear’ that Mr Okon was requesting help for a patient at the CT scanning unit.

‘The confusion came from yourself,’ he said.

‘Yes,’ she replied.

Asked why she didn’t send the team to the correct location once the mix-up had become clear to her, she answered: ‘Sorry, I can’t answer that.’

The inquest in David Horsman's death is being held at Bolton coroner's court (pictured)

The inquest in David Horsman’s death is being held at Bolton coroner’s court (pictured)

Ms Parker wiped her eyes as the coroner suggested she had been ‘disparaging’ of Mr Okon for being ‘foreign’ when he had been clear where the crash team was needed.

But she insisted she had found some of the things Mr Okon said ‘difficult’ to understand.

Asking questions on behalf of scanning unit operators InHealth, Ivor Collett said: ‘He didn’t have a language problem, he simply had an accent. Is that right?’

‘Yes,’ she replied.

Mr Collett said it was ‘pretty plain he speaks the Queen’s English with a thick West African accent’.

Stephen Jones, representing Mr Horsman’s widow, accused Ms Parker of giving a ‘completely inconsistent’ account.

Later Dr Sharmistha Saha, the critical care consultant who treated Mr Horsman after his collapse, told Bolton coroners court that even with immediate treatment there would still have been a ‘significant chance’ he would have died due to heart problems.

But cardiac surgeon Samer Nasef, who was called as an expert witness, disagreed, saying the ‘overwhelming majority’ of patients who suffered an allergic reaction to such dye survived.

Mr Horsman’s cause of death was given as anaphylactic shock, with heart disease a contributing factor.

The hearing continues.

Transcripts of calls, March 27, 2022 

Call one

Idongesit Okon in CT van parked in car park at Royal Bolton Hospital to Anne Parker on switchboard – 15.58

AP – Hello, emergency?

IO – Hello

AP – Emergency

IO – Yeah, please we have an emergency at the CT van, the patient reacted to contrast please.

AP – Which department do you need?

IO – CT van, CT van… hello.

AP – Hello, is it cardiac arrest or…

IO – Yeah, the patient had a reaction to erm contrast and he’s feeling a little bit redness and weakness.

AP – Is it a child?

IO – Sorry?

AP – Is it a child you’re talking about?

IO – Is it what?

AP – Is it a boy, girl, man or woman?

IO – It’s a man, it’s a man.

AP – So is it a cardiac arrest on E5 [the children’s ward]?

IO – Yes please.

AP – I’ll put the call out, thank you.

IO – Please come over quickly please.

AP – I’ll put the call out thank you.

Call two

Idongesit Okon to Anne Parker – 15.59

AP – Hello emergency

IO – Yeah please we have an emergency

AP – I’m just, I’m putting the call out sir, I’ve had a call, I’m just putting the emergency call out.

IO – OK I just spoke to you.

AP – Is it an adult cardiac arrest?

IO – Yeah at the CT van please ok.

AP – I’ll put the call out thank you.

IO – All right.

Call three

Idongesit Okon to Anne Parker – 16.03

AP – Hello emergency

IO – Last emergency, we still need you at the CT van please.

AP – Is it an… I don’t understand are you on E5 the children’s ward?

IO – No we are on the site, erm erm A Block car park, the CT van, just close to the Covid centre.

AP – You’re on A Block car park?

IO – Yes A Block car park, yes, where we have the MRI scanner too.

AP – You said it was on E5, I asked you was it E5 and you said E5.

IO – Oh I didn’t get that.

AP – You have to be precise doctor, I’m sorry I’ve just had all the callers going to E5.

IO – Please, please, A Block car park, A Block car park, just by the Covid centre.

AP – You’ll have to call the ambulance lovey if it’s outside, you’ll have to dial 999. If you stay on the line I’ll get you through to 999.

IO – Ok please.

AP – Thank you… for goodness sake.