Dr Peter Ellis, instructed by clinical negligence partner Laurence Vick of Michelmores, represented the Marchant family at the inquest into the death of Calvin Marchant, which concluded in Exeter Coroner’s Court on 26 April 2016.

Mr Marchant, a 48 year old previously fit family man and jeweller, was admitted to the Royal Devon and Exeter Hospital on 2 January 2015 suffering from mild acute pancreatitis. On 3 January 2015 he suffered from confusion and hypoxia, due to undiagnosed lobar pneumonia, and became dependent on oxygen therapy. Due to a hand over failure he was not seen by any doctor on 3 January, in spite of highly abnormal blood tests, and his deteriorating condition. During the evening, he wandered off a ward in a confused hypoxic state, and collapsed and died in a hospital corridor.

An internal hospital investigation following his death found multiple systems and individual defects, resulting in 15 separate recommendations in order to improve patient safety.

Assistant Coroner Lydia Brown, who had earlier directed that there would be a wider article 2 ‘Middleton’ inquiry, returned a narrative conclusion. This noted that multiple errors and omissions had contributed to the death. These included the absence of any weekend management plan, a failure to allocate Mr Marchant to the correct consultant, a failure to act appropriately in response to worsening abnormal early warning scores, so that there was no medical review when his condition deteriorated, and a failure to allocate a one to one nurse before he left the ward.



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