Man hit over head by girlfriend-ex died after being despatched house from A&E

A chartered accountant died because of ‘gross failures’ by two A&E nurses after he was injured in an assault by his girlfriend’s ex-husband, a coroner has ruled.

Matthew Charnock, 35, was rushed to Whiston Hospital after being smashed over the head with an iron wheel brace by jealous Steven Cotterill.

But despite Mr Charnock appearing extremely confused and bleeding heavily from a head wound, nurses failed to order a CT scan and instead patched up the cut and sent him home with painkillers.

Mr Charnock was found unresponsive the next day and taken back to hospital where medics discovered he had a serious skull fracture and was suffering from sepsis and meningitis. He underwent surgery but could not be saved.

Last week Coroner Jacqueline Devonish ruled Mr Charnock was unlawfully killed and that his death was contributed to by neglect by triage nurse Stephanie Keelan and emergency nurse practitioner Paul O’Brien, who failed to order the scan which would have saved his life.

Ms Devonish, senior coroner for Cheshire, said: ‘There was a gross failure to give Matthew basic medical attention and this failure contributed to Matthew’s death. His death could have been prevented and would have been prevented if he had been given a scan and a course of antibiotics. He would have survived.’

The inquest heard that Mr Charnock died in March 2016.

In the weeks before, he had begun dating a colleague from work, Natasha Cotterill, then 34. 

Although her estranged husband knew about the affair, on the evening of Sunday March 13, Cotterill left work early and found the pair enjoying a takeaway together. He chased unarmed Mr Charnock down an alleyway and attacked him.

Following a three-week trial at Chester Crown Court, Cotterill, then 39, was convicted of Mr Charnock’s manslaughter and jailed for seven years.

Nurse O’Brien was also investigated and interviewed by police, who found Mr Charnock’s treatment to be ‘sub-optimal.’ But the nurse was never charged after the Crown Prosecution Service decided there was no realistic prospect of convicting him of gross negligence manslaughter.

The two-day inquest, in Warrington, heard that that when Mr Charnock arrived at the hospital, around 12.15am, triage Nurse Keelan, who did not give evidence, noted that Mr Charnock was ‘confused’ and should have been given a Glasgow Coma Score of 14 out of 15, which would have been a ‘trigger’ for a CT scan.

But she ‘misrecorded’ the score as 15 and, when his care was taken over by Nurse O’Brien, he simply cleaned and glued the wound shut, before allowing him to go home with his girlfriend.

The following day Mr Charnock was rushed to Salford Royal Hospital in a semi-conscious state where doctors performed emergency surgery on the fractured skull. But by then it was too late. He died on March 16.

Mr O’Brien, who gave evidence at the inquest, admitted he thought Mr Charnock’s injuries were superficial.

‘On reflection, due to the head injury it may well have been better for him to be observed for a longer period of time,’ he said.

Mr Charnock’s gas consultant father, Terry, 73, told the hearing Nurse O’Brien had failed to refer the head injury to a senior doctor, failed to ask for a CT scan and failed to listen to advice that their son should be kept in overnight for observation.

‘O’Brien did not act on the very real dangers of contracting sepsis,’ Mr Charnock snr, said. ‘He glued the head injury and sealed the bacteria in.’

Dr Colin Read, an expert in emergency medicine, said: ‘Nurse O’Brien fell significantly below the standard of care expected of an emergency nurse practitioner. Even a lay person would recognise a blow to the side of the head with a metal bar is a significant injury.’

The coroner agreed there had been a breach of care when there had been a ‘serious and obvious risk of death.’

‘It is without doubt that it was reasonably foreseeable that a doctor would have undertaken a CT scan and Matthew would have been treated with antibiotics to avoid infection,’ Ms Devonish said.

‘Had Matthew had a CT scan, he would have received appropriate treatment – that breach of care caused his death. Both nurses failed to consider the mechanism of the injury and failed to consider whether a scan should be undertaken.’

But Ms Devonish said that the nurses’ actions could not be classed as ‘deliberate criminality’ – the test for a ruling of gross negligence manslaughter.

Earlier in the inquest, Dr John Matthews, the clinical director for Whiston Hospital’s emergency department, said Nurse O’Brien had made ‘a judgement error’ and discussions should have taken place with a doctor before Mr Charnock was sent home.

‘The information that he had been hit on the head with a metal bar should have given rise to a suspicion of a potential fractured skull,’ Dr Matthews said.

‘It is clear that a scan should have been performed.’

Scott Rutherford, a neurosurgeon at Salford Royal, said Mr Charnock could not be saved because a combination of meningitis and sepsis had infected his brain through the injury.

‘If a scan had been carried out, we would have started with antibiotics and removal of bone fragments and tissue from the brain,’ he said. ‘If this had happened in a more timely fashion, then I think it is very likely that we would not have had this outcome. But we had no way to turn. It was a condition which was not medically reversible.’

Following the hearing, Mr Charnock snr and his wife, Jean, who fought to get their son’s inquest re-opened, said they were ‘delighted’ the coroner had recognised their son’s death was contributed to by neglect at the hospital.

The couple, of Sale, Greater Manchester, said: ‘We’ve been fighting for eight years to get recognition and some accountability that Matthew was failed when he was treated at Whiston Hospital.

‘For a coroner to find that any death is contributed to by neglect is rare but this is the correct, and best outcome we could have hoped for for Matthew. We’re particularly grateful to our lawyer Sefton Kwasnik and to Pc William Davies who stayed with Matthew at the hospital in his hour of need. Matthew’s death has left an empty void in our lives. We know he is not coming back, but coming to terms with this is so hard. We loved him so much.’

The court also heard that changes had been made to the way head injuries were triaged and assessed at Whiston Hospital in the wake of Mr Charnock’s death.