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18 January 2023 | Comment | Article by Mala Patel

Death of a ‘brilliant young man’ would have been avoided, Coroner rules

An inquest into the death of a 22-year-old man from Littleborough, who was described by his mother as ‘brilliant’ and ‘talented’ with big plans for a future as a musician, has ruled that he died from natural causes but that his death could have been avoided had his cardiac abnormalities been identified and treatment instigated.

 

Johnny Alfrey began suffering from vomiting, shortness of breath and difficulty sleeping in May 2022. He put these symptoms down to anxiety initially.

Johnny’s symptoms worsened and he attended the Urgent Care Centre at Rochdale Infirmary a few days later where a cardiac abnormality was identified, and Johnny was noted to have a prolonged QTc interval. He also had abnormal liver function tests which were not reported at that point. Johnny was referred to the cardiology team at Fairfield General Hospital but ultimately did not attend as, according to his family, he was reassured that the prolonged QTc was benign and was told that Fairfield General Hospital had had an IT outage and that he would therefore be in a hospital corridor overnight and unlikely to be seen until the next day.

Johnny attended the A&E department at Fairfield General Hospital two days later complaining of heart palpitations, difficulty breathing and vomiting. An ECG again showed a prolonged QTc interval. Johnny also had a T wave inversion which can be a sign of heart disease. The clinical impression of the doctors was that Johnny’s symptoms were related to panic attacks and he was sent home with advice to see his GP as his symptoms were considered to be mental health related.

On 28 May 2022, Johnny returned to the Urgent Care Centre at Rochdale Infirmary as he had ongoing vomiting and was feeling very unwell with extremely low blood pressure. The focus of the treating doctors was now on Johnny’s abnormal liver function test results which had not previously been communicated to him due to the IT outage. The clinical impression was that Johnny was suffering from hepatitis and/or sepsis.

Johnny was transferred to Fairfield General Hospital as he had not responded to treatment and continued to deteriorate. He was admitted to the Acute Medical Unit and an ECG again confirmed a prolonged QTc interval. Doctors continued to treat him for acute hepatitis without considering the urgency of his prolonged QTc heart trace. Johnny was permitted to leave hospital on 31 May 2022 on the basis that he would undergo blood tests the following day to monitor his condition.

Sadly, Johnny’s symptoms persisted, and he also began to experience bloating of his abdomen as well as shoulder and abdominal pain. He returned to the Urgent Care Centre at Rochdale Infirmary on 7 June 2022 and was swiftly transferred to Fairfield General Hospital. By this stage, Johnny’s kidneys were failing, and he was treated for this as well as his liver. The prolonged QTc persisted and was not acted upon – the family believe this was down to Johnny’s age and a focus on other incorrect diagnoses. The Coroner heard at the inquest that Johnny was in a very high level of distress and anxiety during his time in hospital.

At hospital, Johnny ‘crashed’ and required resuscitation. He was put on life support in the Intensive Care Unit. It was not until the next day that the significance of Johnny’s heart issues were finally considered and he was transferred to Wythenshawe Hospital in a state of cardiogenic shock. He was taken straight to theatre for emergency heart surgery in the cardiothoracic critical care unit.

Tragically, Johnny’s organs continued to fail, and life support was withdrawn on 24 June 2022.

A subsequent post-mortem examination indicated that Johnny had died of multi-organ failure caused by acute cardiac failure of unascertained aetiology.

Prior to the Inquest, Northern Care Alliance NHS Foundation Trust produced an incident investigation report regarding the care provided at Rochdale Infirmary and Fairfield General Hospital. The findings were that Johnny was not referred for a timely cardiology review in light of his cardiac abnormalities and instead the focus had been on his liver problems. An action plan was prepared to address and prevent re-occurrence of the shortcomings identified within the report.

 

if you would like to speak to someone about the topics discussed in this post, get in contact with our Clinical Negligence team.

 

Johnny’s parents, Julie Alfrey and Chris Charnley, instructed solicitors at Hugh James to represent them at the inquest into Johnny’s death, which took place on 5 and 6 January 2023. Mala Patel, Associate in the clinical negligence department, instructed Jonathan Bertram, barrister at 7BR Chambers to ask questions on behalf of the family into the care Johnny received.

The Coroner heard evidence from Johnny’s parents, GP, the doctor involved in preparing the Trust’s incident investigation report, a cardiologist involved in the Trust’s investigation and the treating cardiac surgeon at Wythenshawe Hospital, Professor Venkateswaran.

The Coroner delivered her conclusion on 12 January 2023 which was that Johnny’s heart abnormalities indicated the need for an inpatient cardiology referral for an echocardiogram during Johnny’s hospital admission from 28 May 2022. This would have identified Johnny’s cardiac abnormalities and management via medication would have commenced. Had there been no improvement in Johnny’s condition then he would have been transferred to Wythenshawe Hospital for surgery. These events would have taken place before Johnny’s severe deterioration on 8 June 2022 and whilst he was still in a stable condition. The Coroner ruled that had Johnny’s cardiac abnormalities been acted upon on and after 28 May 2022 then Johnny would not have died on 24 June 2022.

Commenting on the verdict, Julie Alfrey and Chris Charnley, Johnny’s parents said:

"Johnny was a good man at the very start of his adult life. Amongst many shining attributes Johnny was a musician, a performer, a lyricist, a comedian, a leader and an intellectual. Our home is much quieter without him and we year to have the house filled with his voice and music once again.

"Our lives have been shattered by his loss, forever altered by biased assumptions and a blindness to our concerns.

"We watched Johnny suffer a slow and traumatic death whilst we tried, to no avail, to persuade medics to see the bigger picture…but they were already focused on a ‘best fit’ for his symptoms.

"We want to thank Professor Venkateswaran and his team for their attempt to save his life at Wythenshawe Cardiothoracic Critical Care Unit. Despite their best efforts, Johnny had suffered irreversible damage over the two weeks he spent in and out of the North West hospitals.

"We are angry, bitter, and bereft. We are broken, much like the system that is the NHS.

"Johnny has many friends who will celebrate him through our music charity work. His university have remembered him with an award for excellence in history in his name. His brother and sister are forever influenced by his values and artistic talent. Johnny has no doubt changed many lives for the better and we will continue to do this for him through his charity and by campaigning for change through our story.

"We continue to be supported by some very caring individuals in the NHS. We would like to thank our bereavement nurse and our family’s GP as well as our counsellors from Cardiac Risk in the Young (CRY) and our legal team.

We would lastly like to thank all the kind and loving people around us who have made a difference to us the smallest of ways.”

Mala Patel, Associate in the Clinical Negligence department at Hugh James, added:

“This is an extremely tragic case which shines a light on how the significant signs of cardiac abnormality were missed and not acted upon in a young man. I hope the sad circumstances of this case can result in greater awareness amongst clinicians and a change in practices to prevent re-occurrence of these tragic events in the future. I wish to pay tribute to Johnny’s parents Julie and Chris who have shown enormous strength throughout the inquest process.”

Disclaimer: The information on the Hugh James website is for general information only and reflects the position at the date of publication. It does not constitute legal advice and should not be treated as such. If you would like to ensure the commentary reflects current legislation, case law or best practice, please contact the blog author.

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