Family shocked as patient’s ‘minor wound’ turned out to be fatal injury
- Credit: Archant Â© 2011
The family of Adam Frere-Smith said they were shocked to learn the failed GP trial had cost more lives.
In a statement after the inquest the family said: 'We are utterly devastated by the loss of our father, son, and brother Adam, and listening to the evidence in court today has been unimaginable.
'We accept the trust's acceptance of the systemic failure which significantly contributed to Adam's death.
'We are disappointed that as a family we have not been kept informed of the trust's updated action plan and are shocked to learn that Adam's death was not an isolated one during this trial.
'Our hearts go out to their families.
'While there was a timely response to the initial call which is indicative of effective frontline service, Adam was let down by the trust's systemic failures – and for our family we have paid the ultimate price.'
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Dr Tom Davis, EEAST's deputy medical director, said: 'The trust recognises that mistakes were made in the care of Mr Frere-Smith, who should have been taken to hospital.
'Both clinicians will be going through a thorough review of the incident.
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'Further guidance is being sent to all staff regarding patients with head injuries and alcohol consumption.'
It was thought to be just a minor wound, but in reality Adam Frere-Smith had suffered a brain haemorrhage and fractured skull.
The failure to diagnose this, and the decision not to take him to hospital, proved fateful for the 48-year- old Cromer man.
Towards the end of his life Mr Frere-Smith battled alcoholism, as well as anxiety and depression, which led him to move from Cromer to live with his mother, Patricia Frere-Smith, in Pearcefield, Norwich, in a bid to improve his health.
In a statement read out at the inquest, Ms Frere-Smith said after showing some initial signs of improvement her son 'rapidly deteriorated'.
On November 15 last year, Mrs Frere-Smith found Mr Frere-Smith on the bathroom floor.
It appeared he had fallen and banged his head on the basin next to the toilet.
Mr Frere-Smith was bleeding from his head but paramedic Jeff Billings, who was called to treat him, thought it was a minor wound.
He cleaned Mr Frere-Smith's wound and, after discussing the case with a GP working with the ambulance service, decided that Mr Frere-Smith did not need to go to hospital.
Mr Frere-Smith then slept for the majority of that night and the following day, with Mrs Frere-Smith making regular checks on him.
On the evening of the 16th – around 24 hours after his fall – Mrs Frere-Smith found her son lying cold and lifeless on the bedroom floor.
She quickly rang for an ambulance again, but despite attempts by paramedics Mr Frere-Smith had died.
Speaking at the inquest Mr Billings said he would normally have taken a person in that situation to hospital, but he chose not to following the conversation with the GP over the phone.
That decision was taken despite guidelines from the National Institute for Clinical Excellence stating that patients with head injuries should be taken to hospital if the patient is intoxicated by alcohol.
Dr Peter Harvey, the GP based in ambulance headquarters who spoke to Mr Billings on the phone, told the inquest: 'I felt I wasn't being asked about the head injury – my role was to satisfy myself that he [Mr Frere-Smith] had help with his ongoing problems like the alcoholism.'
When asked about the trial Dr Harvey, a GP in Holt, said the expectation of paramedic and GP 'didn't match'.
Johanna Thompson, assistant coroner for Norfolk, recorded a verdict of accidental death.
Born in Stalham, Adam Frere-Smith was one of 12 siblings and the father of four children: Oliver, Jessica, Wesley and Esme.
Mr Frere-Smith co-founded North Norfolk Surf Lifesaving Club and was a key figure in helping it grow from a handful of members to more than 100.
It was one of the first clubs of its kind in the east of England.
He introduced three training categories and successfully applied for funding to convert the former toilets at the foot of the Red Lion steps into a training centre and clubhouse, a shower and storage area.
He also helped secure more than £10,000 for training and lifesaving equipment.
Many club members have gone on to work as lifeguards in the area and Mr Frere-Smith himself volunteered countless hours patrolling local beaches.
His commitment to surf -lifesaving, and the club, was recognised in 2012 when he won national awards for both services to the community and services to lifesaving.
Last month dozens of people took part in a memorial paddle in Cromer in memory of Mr Frere-Smith. A new award, the Adam Frere-Smith Award, has been launched at the club to recognise dedication and commitment to surf lifesaving among its members.