David Nash was a 26-year-old University of Leeds law student who died on 4th November 2020 in Leeds General Infirmary, where he had been admitted two days earlier following complaints of becoming delusional, feverish and suffering from a pain in his neck, behind his eyes, of blocked sinuses and exhaustion for a period extending to a week.
The deterioration in David’s condition followed four separate consultations with his GP, the Burley Park Medical Centre in Leeds, over a period of nearly 3 weeks, during which he was never seen face-to-face and was only diagnosed over the phone. David was eventually admitted to hospital after he and his concerned partner dialled 111, but in his delusional state in hospital he became disorientated and fell off a hospital trolley. In his attempts to restore balance he struck his head on a table and became unconscious. Although this accident was not directly related to his death, he never regained consciousness and died in the intensive care unit of the hospital two days later, when his parents consented to turning off his life support machine.
In the lead-up to the Inquest into David’s death, held at Wakefield Coroner’s Court in January 2023, Ison Harrison’s Clinical Negligence solicitor Iain Oliver, representing the family, said “David’s family would like the inquest into his tragic death to raise awareness of various issues, including the need for GP practices to see patients face-to-face to enable proper assessment of conditions to be made that will be missed during a telephone consultation.
“They would also like to highlight the need for continuity of care within GP practices to ensure that the patient is considered holistically, particularly where there are repeated consultations for a developing condition that may be identified by such an approach.”
Inquest Findings
The Inquest into the death of David Nash was held at Wakefield Coroner’s Court. It began on 16th January 2023 and was heard by Ms Abigail Combes, Assistant Coroner for South Yorkshire. During the course of 3 days of evidence the Coroner heard from staff and partners at David Nash’s GP practice, Burley Park Medical Centre as well as from NHS Digital, Yorkshire Ambulance Service, NHS England and The Leeds Teaching Hospitals NHS Trust (the Trust). Various expert witnesses also gave evidence, including Dr Alastair Bint (a GP expert), Dr J D’Souza (also a GP) and Mr S Howarth (a Consultant Neurosurgeon).
The inquest opened with a moving pen portrait of David Nash read out by his mother Anne Nash, in which he was described as a “wonderful son, brother and friend” with a strong sense of right and wrong and who always looked out for others. This reading also included poignant quotes from friends and former bandmates, his girlfriend Ellie and her parents and also from David’s sister Katie, emphasising how strong, loyal and fun-loving David had been as a son, brother and friend.
During the three days of inquest evidence the following issues were highlighted:
- David had contacted his GP on four separate appointments between 14th October and 2nd November 2020 as his symptoms (including stiffness, headaches, jaw pain and a fever) developed. On each occasion he was spoken to by a different clinician (none of whom were his allocated GP), meaning the opportunity for continuity of care was limited.
- Due to the COVID-19 pandemic most consultations at Burley Park Medical Centre took place by telephone rather than in person, this included all four of David’s consultations. During the fourth consultation on 2nd November 2020, David was advised not to attend for his planned blood tests that day, due to having developed a fever. The Advanced Nurse Practitioner conducting David’s appointment thought these symptoms might indicate he had contracted COVID-19, despite him completing a negative test, and despite the fact that the Practice had a “hot room” where those with suspected COVID-19 symptoms could be seen.
- David and his partner also consulted NHS 111 on several occasions during 2nd November 2020, but the NHS Digital algorithm directed him down the ‘dental pain’ pathway based on the answers he gave. This resulted in David not being considered a priority. However, one call handler phoned him back to go over his answers again, because she was so concerned about him based on the information he had provided. NHS Digital have accepted that the system could be improved in this regard, and the digital algorithm has since been amended to make it more sensitive, with the aim of helping call handlers to more accurately advise patients with serious conditions such as David’s.
- After David had contacted the 111 service for a fifth time that evening, and following a deterioration in David’s presentation, an ambulance was sent to take him to hospital. There were some delays in arranging a scan of David at St James’s Hospital and whilst awaiting a transfer from there to Leeds General Infirmary, David’s condition deteriorated further. David was prescribed with intravenous antibiotics and antiviral medication due to concerns that he was suffering with meningitis or encephalitis. David became disoriented and fell off the trolley and hit his head when he attempted to regain his balance. David lost consciousness, and would never regain it, though the fall did not in any way contribute to his subsequent death.
- David was transferred to Leeds General Infirmary in order for surgeons to relieve pressure on his brain. This was being caused by a cerebellar abscess. The abscess burst and David suffered extensive damage to the tissues of his brain. He died on 4th November 2020 after his parents consented to the withdrawal of life support. Since he never regained consciousness, they were unable to speak to him before he died.
Inquest Conclusion
During evidence, Drs Bint and D’Souza were not critical of the first three consultations David received via the Burley Park Medical Centre. However, they agreed that during the fourth call on the morning of 2nd November 2020, there were ‘red flags’ in David’s presentation that should have alerted staff to the severity of David’s condition and led them to ensure he saw a doctor urgently and face-to-face.
Dr Bint’s report concludes that the diagnosis reached by the Advanced Nurse Practitioner during David’s fourth consultation was ‘not safe’. The report states that “this was a patient that needed to be seen in person” and that “had he been seen in person, it seems likely to me he would have been admitted to hospital”.
The Inquest heard that, had David been seen face-to-face following the fourth consultation and therefore been referred to hospital, he would have been seen by a consultant approximately 10 hours sooner than he was. Mr Howarth assisted the Coroner with the conclusion that if David had been seen by a consultant 10 hours sooner he would probably have survived.
Coroner Abigail Combes concluded that David Nash died at Leeds General Infirmary due to a brain-stem infarction (tissue death in the brain stem) arising from a cerebellar abscess (an infection in the brain) that in turn had arisen from an undiagnosed mastoiditis (a serious bacterial infection in the mastoid bone behind the ear).
In her concluding statement, the Coroner said: “I have considered, in line with the Chief Coroners Guidance, whether a short form conclusion would be appropriate in David’s case. The only possible conclusion which I could return in a short form would be one of natural causes, and it is plain from the description above that this would not be sufficient to adequately reflect the circumstances of David’s death. For that reason I will return a narrative conclusion as follows:-
David died on 4 November 2020 at Leeds General Infirmary as a result of a brain-stem infarction, arising from a cerebellar abscess caused by mastoiditis. 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 he would likely 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.”
Dr Neil Lawton, a partner at Burley Park Medical Centre, issued a statement saying he believed that a repeat of the David Nash failings would no longer occur due to changes in policies and procedures following the COVID-19 pandemic and implemented since 2nd November 2020. However, he also concluded that “as a practice we accept that David should have been seen in a face-to-face appointment on 2nd November 2020 and wish to apologise to his family and friends that he was not dealt with in that way on 2nd November.”
Timeline of events in the death of David Nash
Here is the timeline of events as described at the David Nash Inquest:
Events from 14 October 2020 to 2 November 2020
- David first spoke to his GP on the phone about some swollen lumps on his neck on 14 October 2020. He was advised that he should have blood tests and these were booked for 2 November 2020.
- On 23 October 2020 he further sought advice from the GP because he had pain in his ear and was complaining of an ear infection. At this telephone appointment there was an assessment for mastoiditis and otitis externa was diagnosed. Antibiotic ear drops were prescribed.
- He was then spoken to on the phone again on 28 October 2020 because he felt that he had blood in his urine. He was advised to deliver a urine sample to the Practice which he did and when tested contained blood and white cells resulting in further antibiotics being prescribed. The view of the GP expert was that this was unlikely to be a UTI, however there would be no basis on which a GP would link these symptoms to mastoiditis and therefore the treatment was not unreasonable on this occasion.
- From the evidence of Dr Murphy, ENT consultant it is more likely than not that at some point in the days after this appointment, David began to develop the abscess that would ultimately prove fatal.
- On 2 November 2020 David had a telephone consultation with an ANP at his practice. He had continued fever, pain behind his eye and sinus pain. He had had a negative COVID-19 swab in the week prior to this appointment but nevertheless his blood tests were cancelled and he was advised not to visit the surgery but to take a further COVID-19 swab and await the results. This clearly unsettled David who was concerned to get his blood tests completed and the ANP gave reassurance that as soon as he had a negative COVID-19 swab she would book him in for his blood tests and see him urgently in practice.
- As the 2 November 2020 progressed David became increasingly unwell. This resulted in David’s partner contacting NHS 111. She explained his symptoms and was advised that a clinician would call back within 6 hours. Unfortunately David then vomited and so his partner called NHS 111 again and was given the same advice. When a clinician did call, David’s partner was advised not to wake him if he was sleeping and to keep up to date with the codeine pain relief. About an hour later David began to be disorientated and his partner made a final call to NHS 111 resulting in an ambulance being called.
- David was placed on the dental pathway for NHS 111 which meant that he missed the opportunity to be asked questions which may have identified mastoiditis. However this pathway at the time was not unreasonable for him on the basis of his symptoms.
- David was taken to St James’s Hospital initially. He was triaged quickly and a working diagnosis of either meningitis or encephalitis was made. Both of these conditions could be treated at St James’s. He required a CT scan which was undertaken just over two hours after it was booked. This was within the context of an ED suffering significant pressures.
- As soon as the CT scan was undertaken it was apparent how unwell David was and urgent steps were taken to transfer him to the LGI for neurosurgery.
- Unfortunately whilst David was in the resuscitation part of ED he deteriorated very significantly and suffered a fall resulting in head lacerations. This fall did not contribute to his death but nevertheless coincided with an acute deterioration in his condition with his GCS going from 10 to 3 and requiring immediate ventilation.
- David survived transfer to the LGI and underwent surgery to insert an external ventricular drain. This appeared to be a successful procedure at first and David responded, however he continued to deteriorate over the course of the 3rd and 4th of November 2020 and clinicians determined that his condition was unsurvivable.
- David died at the LGI on 4 November 2020.
Family Statement
Following the Inquest conclusion, Anne and Andrew Nash, David’s parents, issued the following statement:
“As a family we have been devastated by David’s death. He was our wonderful son, brother and friend. He had a strong sense of right and wrong, and always looked out for others. We in turn have spent two years seeking answers on his behalf, and to make sure that others don’t die as David did. We know that is what he would have wanted.
“We are relieved and grateful to Coroner Abigail Combes for concluding that, despite the pressures of the COVID pandemic, David could, and should, have been seen face-to-face at Burley Park Medical Practice on the morning of 2 November 2020, and that this would probably have led to a hospital admission, and earlier care. We are both saddened and vindicated by the finding that the simple, and obviously necessary, step of seeing him in person would have saved his life.
“As we have heard, there were missed opportunities in terms of the 111 calls that were made on David’s behalf later that day, and there were mistakes made at the hospital, but David was already extremely unwell by the afternoon of 2 November, and it is unclear whether he could have been saved by different steps having been taken. We believe that the neurosurgeons who tried to save his life with emergency surgery were trying their best for him. Our main focus has always been on the fact that he should never have been allowed to deteriorate to that point in the first place.
“We are relieved that the organisations involved in David’s care have made changes to their policies and procedures following this inquest process: we hope that, by shining a light on his case as we have done, we will have helped prevent future deaths from occurring, and that we have done David justice.
“Finally, we want to take this opportunity to thank all those who have supported us in this difficult process and also wish to thank Iain Oliver from Ison Harrison Solicitors and our barrister, Rose Harvey-Sullivan from 7 Bedford Row Chambers. Their support, assistance and guidance has been invaluable to us.”
Iain Oliver, Clinical Negligence Solicitor at Ison Harrison, representing the family of David Nash, also commented:
“We are pleased that the Coroner conducted such a thorough investigation and inquest into David’s death. The scope of the inquest became wider than initially expected due to the possibility that the issues with NHS 111 or indeed at the hospital may have contributed to David’s passing and the family are grateful to the Coroner’s Service for permitting these avenues to be explored as well as grateful to NHS Digital and the Trust for their candour.
“This inquest has highlighted the limitations of telephone consultations with GPs and the need for patients to be seen in person wherever that is possible to ensure that proper assessment of conditions can be made. It has also highlighted the need for continuity of care within GP practices to ensure that the patient is considered holistically, particularly where there are repeated consultations over a short period of time.
“The GP practice, in a statement read by the Coroner today, has assured the Coroner, from the point of view of preventing future deaths, that their procedures have been reviewed and altered such that what occurred in David’s case is very unlikely ever to happen again.”
David Nash Inquest Media Coverage
The tragic death of David Nash and his parents’ two-year quest for answers, has been reported widely in both local and national media.
In the days leading up to the Inquest, the story was reported in regional newspapers as well as national titles such as Daily Mail, BBC and ITV. This press attention increased upon the Inquest conclusion, and following the Inquest, David’s parents Anne and Andrew Nash were interviewed by Channel 5, ITV, the Press Association, BBC Newsnight, Look North, Calendar News, ITN and the Guardian.
Ison Harrison have closely followed the story and circumstances of David Nash’s death in the lead-up to the Inquest, reporting on the various stages of the process.
Read our David Nash Inquest news and coverage:
https://www.isonharrison.co.uk/blog/inquest-opens-into-death-of-david-nash/
This coverage concludes with a post-inquest press release issued upon the conclusion of the Inquest on 20th January 2023:
