Inquest of Tottenhill man Paul Leake hears his death in King’s Lynn hospital following A10 crash could have been prevented
A postman died after being hit by a driver who failed to stop at a high-speed junction - but his hospital treatment has also led to an overhaul of healthcare policies.
Tottenhill resident Paul Leake died in Lynn’s Queen Elizabeth Hospital on December 16, 2021, just days after being involved in a crash while on his way to work.
St Germans man Darren Godfrey later pleaded guilty to causing death by careless driving, having failed to stop at a junction onto the A10 at Tottenhill as Paul was riding his motorbike to work.
Today, at Paul’s inquest, senior coroner for Norfolk Jacqueline Lake concluded that he died as a result of that road traffic collision, having been bound by Godfrey’s proceedings at Norwich Crown Court.
However, the inquest heard that a serious incident investigation was carried out at the QEH after Paul passed away at the age of 50, with “inadequate” care meaning he was at times left “isolated and relatively unsupervised”.
It was established there was a “strong possibility” his death could have been prevented.
Since then, the hospital trust has used the case as a focal point in training programmes in a bid to “improve patient safety”.
THE CRASH THAT LED TO PAUL’S DEATH
On December 13, 2021, Paul woke for work at 5.30am - the same as he did on every other day.
He gave his partner, Tina Sawyer, two kisses, put his helmet on and left for his shift. He had worked as a postman in the Lynn area for 34 years.
In a statement read at today’s inquest, Tina said: “He knew a lot of people on his rounds and would always take time to stop and talk to people.”
She described him as “bubbly” and “easy to get on with”.
Paul took his normal route to work, leaving his house at 6.15am. However, his mother soon phoned Tina to say she had been told that Paul had not arrived for his shift.
It transpired that as Paul was riding his Honda motorbike along the A10 at Tottenhill, Godfrey had pulled out of the Watlington Road junction in a Land Rover Discovery without stopping, with both vehicles colliding.
In subsequent police interviews, Godfrey said he was “adamant” he had stopped at the junction and was unable to provide any explanation as to why he had not spotted Paul despite his headlights being illuminated.
“I just didn’t see him,” Godfrey told officers.
Police investigations and data taken from Godfrey’s vehicle revealed that as he was approaching the junction, he slowed from 35mph to 5mph before accelerating again to a speed of 10.7mph immediately prior to the crash.
An investigating officer therefore said he was as “confident as can possibly be” that Godfrey did not stop, while it was established that Paul had been travelling within speed limits along the 60mph A10.
Paul was admitted to the QEH with injuries, but Tina was informed that he was awake and talking.
TREATMENT IN HOSPITAL
The results of a serious incident investigation report carried out at the QEH were read aloud at today’s inquest.
Paul was brought into the emergency department at around 7.25am after the crash. The Lynn hospital does not handle major trauma cases, but it was established that a transfer to Addenbrooke’s in Cambridge was not necessary.
Paul was originally stable - his pupils were ordinary, his airway was clear and his spine was stabilised.
In the crash, he had suffered fractures to his ribs and wrists.
A membrane attaching his intestines to his abdominal wall had also suffered a tear, but this was not initially detected. However, it was later established that this would not have affected his care plan.
Paul was transferred to the hospital’s critical care unit (CCU). A procedure to fix his arm fractures was postponed due to “high clinical demand”.
At this stage, Paul was deemed “stable”. However, he was being cared for by two teams, with confusion as to whether the orthopedic team or general surgery staff were in charge of his case management.
Hospital policy stated that only one team should be primarily responsible for a patient’s care.
On December 15, Paul was discharged from the CCU and moved to the hospital’s Denver ward, being placed in a side room despite no risk assessment being carried out to determine if this was suitable.
Paul reported that he was having trouble with coughing, and appeared “confused” throughout the duration of his spell in the ward.
At one stage, the registered nurse monitoring Paul left the ward for 14 minutes when it was already one staff member short for the shift.
Today’s inquest heard that Paul’s Value of Modified Early Warning Score (MEWS) continually worsened throughout the night, which should have prompted a review into whether he should be re-admitted to the CCU.
However, this never took place.
In the early hours of the following morning, he became “critically unwell”. A chest X-ray was requested, but he soon began regurgitating “dark” and “coffee” coloured vomit.
Paul went into cardiac arrest, with QEH staff attempting to resuscitate him. However, he was pronounced dead at 4am after their efforts were deemed “futile”.
His family were only alerted that his condition has worsened at this stage.
The hospital investigation subsequently discovered that Paul had been subjected to “inadequate pain monitoring and inadequate pain management”, while staff missed “multiple opportunities for appropriate escalation to take place”.
He was left “isolated and relatively unsupervised” in a side room, with staff “exceptionally busy” and facing “many distractions”.
The investigation also found that some junior staff were afraid to escalate certain cases out of “fear of negative repercussions” from their seniors.
It concluded that there were “persistent failures around a deteriorating patient” - and that there was a “strong possibility” Paul’s death could have been prevented.
WHAT HAS HAPPENED AT THE HOSPITAL SINCE?
A statement from Emily Hodges, the QEH’s critical care clinical governance nurse, outlined the steps that have been taken at the hospital since Paul’s death in a bid to ensure similar incidents do not occur again.
A 40-point action plan was drawn up, which included a trust-wide scheme to improve understanding of deteriorating cases.
It has also been made easier for patients and their relatives to request urgent independent clinical reviews if they feel their concerns are not being treated adequately.
Ms Hodges said patient handover between departments has “improved significantly”, while documentation of patients’ pain levels and medication has been bolstered with online systems.
The Denver ward where Paul died has also benefited from an extra staff member being employed for day and night shifts.
THE AFTERMATH
Godfrey was handed a 12-month community order after admitting causing Paul’s death by careless driving.
At today’s inquest, Ms Lake said she was bound by that crown court outcome when ruling the cause of Paul’s death.
“On that basis, my conclusion can only be road traffic collision,” she said.
However, the coroner did say that Paul’s “deteriorating condition was not recognised and escalated” at the QEH.
She added: “There has been an investigation carried out by the QEH… and several serious concerns have been raised.”
Ms Lake offered her sympathies to Paul’s family.
A statement from the QEH trust’s medical director, Rebecca Martin, said: “On behalf of the trust I reiterate our sincere condolences to Mr Leake’s family.
“The level of care which Mr Leake received at our Trust fell below the standard we strive to achieve and below the level he was entitled to expect.
“We carried out a thorough investigation following the death of Mr Leake which highlighted to us some areas which we have worked hard to improve.
“This includes a significant amount of work around our management of deteriorating patients, safety huddles to improve communication between staff and providing additional opportunities to escalate concerns about patients, including through Call for Concern.”
