EMOTIONS ran high at the inquest into the death of Gainsborough dad-of-one Dean Beresford last Wednesday as the court was played a recording of his call to NHS Direct.
Mr Beresford, 44, of Forster Street, died on 11th August last year of a massive heart rupture, just days after doctors failed to diagnose a smaller heart attack.
The inquest at Lincoln Registration Office heard evidence that doctors could have prevented his death, had they been more thorough.
Instead, he was passed between four people and misdiagnosed with a chest infection.
On the morning of Saturday 31st July Mr Beresford was encouraged to call the NHS Direct helpline by his partner Tina Coupland.
Ms Coupland wept in court as she heard him telling a nurse he had been having shooting pains in his chest and arms.
He also complained of being breathless when exerting himself just slightly, and a bit of a cough which he put down to being a smoker.
Andrea Bennett, who managed the NHS out of hours service in Lincolnshire, said the nurse should have called 999 within the first minute of speaking to Mr Beresford.
Coroner Stuart Fisher asked her: “She appeared to be out of her depth?”
Ms Bennett replied: “In my professional opinion, yes.”
Expert GP witness Dr Stephen Hicks said after hearing the tape he thought Mr Beresford had given symptoms which ‘clearly pointed to the possibility of a heart attack or angina’.
He said the nurse’s interpretation of the symptoms were ‘fundamentally in error’.
Shockingly, nurse Beatrice Makonyola advised Mr Beresford his symptoms were not associated with a heart attack, but a chest infection.
She got a doctor at Lincoln County Hospital, Dr Richard Smith, to call him back, and he went over his symptoms for the third time.
Dr Hicks said the actions of the nurse and Dr Smith were ‘inadequate’. They failed to heed Mr Beresford’s own advice that heart disease ran in his family.
His mother died after an angina attack aged 50, and his father had a heart attack at 65.
Dr Smith booked an immediate appointment with out of hours GP Dr Kevin Lee at John Coupland Hospital in Gainsborough.
But even Dr Lee did not pick up on the tell-tale signs of a heart attack, instead relying too heavily on the notes sent by Dr Smith.
The inquest heard Dr Lee did not take Mr Beresford’s temperature or blood pressure.
He listened to his chest and prescribed antibiotics.
Andrea Bennett confirmed a 12 lead ECG heart monitor was available in the same building, had Dr Lee thought to use it.
The inquest heard how Mr Beresford returned home ‘relieved’ that his diagnosis was simply a chest infection.
But he continued to feel ill and stayed in bed all week.
On Tuesday 9th August he returned to his job as a lorry driver for Jackson Shipley.
Ms Coupland said he was tired but did not complain of any pain.
She said in a statement: “I didn’t hear him get up on Wednesday morning. The first thing I knew about his death was later that day when his dad called and told me.”
Mr Beresford was found collapsed in a toilet cubicle while making a delivery in Navenby.
His supervisor Raymond Tobin said: “I have lost a friend and not a day goes by I don’t think about him. Dean was so fantastic with customers and such a happy character. He will be missed by all who knew him.”
The inquest heard an NHS investigation has highlighted a number of errors in the way Mr Beresford was dealt with, and has prompted changes in procedure.
The coroner has adjourned the inquest until 31st January, summoning the head of NHS Direct and nurse Makonyola to give evidence.
“I will ask NHS Direct what their plans are to stop anything like this happening again,” said Mr Fisher.