A Walthamstow man died of heart problems after spending a day in Whipps Cross Hospital without being seen by a doctor.
Muhammad Tariq, 55, died in the late hours of August 7 last year after being admitted with radiating neck pain and heart palpitations at 4.50am.
Mr Tariq was sent to an acute assessment ward, where he remained without being checked by doctors on their day shift until he was found struggling to breathe at around 10pm.
Doctors fitted a mask ventilator and attempted needle decompression to clear blood they believed had accumulated around his heart but he was pronounced dead at 11.16pm that night.
At an inquest into Mr Tariq's death on April 12 at The Adult College of Barking & Dagenham, assistant coroner Dr Shirley Radcliffe ruled that he died of natural causes linked to heart disease.
However, a senior doctor at the Whipps Cross could not explain why Mr Tariq had stayed on the ward all day without being reviewed in-person by a doctor.
Dr Simon Green, clinical director for acute medicine, said: “It isn’t at all clear why the junior doctors didn’t alert Dr Rizvi about the fact that there was a patient that hadn’t been checked.
“My personal practice is to check the list myself and I believe it is now Dr Rizvi’s procedure. Furthermore, it’s normal procedure for the nurses to flag it to us if a patient isn’t being seen.
“Normally there are safeguards against this happening and it really wasn’t possible to work out why none of those happened on this occasion.”
Giving evidence, on-duty consultant Dr Fareeha Rizvi said she suspected Mr Tariq was suffering from an angina but that most of his tests had come back as “normal”.
She added: “If I had seen him I would have had a very low suspicion of his level of risk, in my past experience these cases are usually very traumatic.
“Mr Tariq was unusual in that when he presented he was quite well, if I had done a CT scan I would have agreed with the plan.”
Summarising her findings, Dr Radcliffe accepted the doctors’ evidence that their plan would not have changed if they had seen him earlier and that efforts were made to treat him on the evening of his death.
She said Mr Tariq’s medical records showed he was pre-diabetic, a smoker and had “significant” hypertension.
His cause of death was recorded as hemopericardium, which is an accumulation of blood in part of the heart.
The assistant coroner offered her condolences to Muhammad’s cousin, Mohammed, who attended the hearing remotely.
Dr Rina Davison, acting medical director at Whipps Cross Hospital said: “We offer our sincere sympathies to the family of Mr Muhammad Tariq.
“Although the inquest concluded he died of natural causes, we assured the coroner we will share the learnings from this case widely across our hospitals.“
Comments: Our rules
We want our comments to be a lively and valuable part of our community - a place where readers can debate and engage with the most important local issues. The ability to comment on our stories is a privilege, not a right, however, and that privilege may be withdrawn if it is abused or misused.
Please report any comments that break our rules.
Read the rules here