A dying man used a whiteboard to tell his wife he “did not feel safe” in a Bucks hospital following a fatal missed diagnosis

Peter Wetherman, from Prestwood, passed away aged 68 on July 21, 2019, at Stoke Mandeville Hospital.

An inquest into his death held on April 7 heard that when he was first hospitalised at John Radcliffe Hospital with pains and shortness of breath, clinicians did not detect an issue in his lungs, and sent him home.

A week later, Mr Wetherman was taken to Stoke Mandeville Hospital, where doctors discovered he was suffering with severe pneumonia, which he was unable to recover from.

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During the inquest, held at Beaconsfield Coroners Court, Mr Wetherman’s widow Janet gave an emotional statement about her husband’s concerns during his stay at Stoke Mandeville, where he was a patient for several days before he died on July 21.

She told the court that as his condition worsened, he could only breath with the assistance of intubation, and could only communicate with her using a whiteboard and pen.

She said: “He wrote things that were distressing for me to read, about how afraid he felt, for me to watch, listen and remember, and that if anything happened to him, he wanted a post-mortem.

“He wrote ‘I am not safe, take a photo and take me to a safe place, you must believe me.’

“I accept that Peter was very unwell, but he didn’t feel safe and that thought continues to upset me.”

Bucks Free Press: Doctors at John Radcliffe Hospital, where Mr Wetherman was first admitted, did not properly diagnose himDoctors at John Radcliffe Hospital, where Mr Wetherman was first admitted, did not properly diagnose him

Mrs Wetherman told the court that the nurse caring for her husband in the ICU at Stoke Mandeville was new and still receiving training – something that worried her husband.

She added: “I’m not saying she did anything bad, but Peter feared whatever it was she was doing, he didn’t want her to continue.

“I know nothing will bring my husband back, but I want to know why he died. I firmly believe if he received better care when admitted to John Radcliffe Hospital, his death could have been avoided.”

During the day-long inquest, the court heard how Mr Wetherman was taken to John Radcliffe hospital on July 6 when he was feeling unwell. Doctors were concerned because he had a history of heart issues.

After conducting the scan, the results showed no sign of any heart problems, so Mr Wetherman was discharged. Before he left the building, a clinician added an addendum to the scan results noting a potential concern with his lungs. However, Mr Wetherman was still permitted to leave the hospital and this information was not passed on to him or his GP.

The court later heard that the scan had detected the early signs of pneumonia, which continued to evolve after the patient left hospital. Had this been noticed earlier, Mr Wetherman may have been prescribed antibiotics and advised to stop taking immunosuppressant medication he was on for his other health issues.

At the inquest, Senior Coroner for Buckinghamshire Crispin Butler told the court that Oxford University NHS Trust accepted there was a “failure” that contributed to Mr Wetherman’s death.

Reading out a statement from the trust, Mr Butler said: “There was a failure to identify and report and follow up on ground glass opacity in the lungs evident on the CT scan and on the balance of probabilities this has contributed to the death of Mr Wetherman.”

At the inquest, Laurence Fitton, a consultant for Oxford University NHS Foundation Trust, told the court that the trust could revisit its decision not to classify Mr Wetherman’s case as a Serious Incident Requiring Investigation.

Concluding the inquest, the coroner ruled that Mr Wetherman’s medical cause of death was pneumonia, and that the missed results on the CT scan contributed to his passing.

Ending the proceedings by providing a narrative conclusion, he said:

“A CT scan undertook on July 6, 2019, reported evidence of ground glass opacity, most likely reflective of lung infection that was not acted upon. Peter was likely to have evolving PCP (pneumocystis pneumonia) at the time of the CT scan, from which he subsequently died.

“Peter Wetherman died from pneumonia. On the balance of probabilities, the fact that lung infection identifiable on a CT scan on July 6 was not acted upon at that time contributed more than minimally to Peter’s death from that infection on July 21."

He added that he will write a letter of concern to Oxford University NHS Foundation Trust, and would also consider issuing a Regulation 28 report, known as a report on action to prevent other deaths.