In-person GP appointment may have saved Leeds student’s life, coroner finds | Leeds


A student who died after being wrongly diagnosed in a series of remote GP appointments during the pandemic would probably have lived if he had been seen in person, a coroner has found.

David Nash, 26, died from brain-stem swelling on 4 November 2020 at Leeds General Infirmary more than two weeks after first reporting symptoms of mastoiditis, a serious bacterial infection of a bone in the ear.

Nash, a talented musician who had hoped to become a barrister, first contacted his GP on 14 October 2020 after finding a lump on his neck.

Over the course of a couple of weeks, his symptoms worsened to include pain in his ear and neck, blood in his urine and a fever, caused by a severe infection.

This infection was not picked up in a number of telephone appointments with GPs and advanced nurse practitioners at Burley Park Medical Practice in Leeds, which was following NHS guidance to carry out most appointments remotely.

He was advised to take painkillers and prescribed antibiotics during three phone appointments in which he was incorrectly diagnosed with an outer ear infection and, later, a urinary tract infection.

When he did not get better and developed a fever, he called for a fourth time, but despite being seriously ill he was not seen in person.

The assistant coroner Abigail Combes told Wakefield coroner’s court on Friday that Nash had been treated appropriately in three appointments, on 14, 23 and 28 October. But on 2 November, when Nash spoke to an advanced nurse practitioner, he should have been given a face-to-face appointment, which would have led to a hospital appointment.

Dr Neil Lawton, a GP partner at Burley Park, said Nash should have been given a face-to-face appointment and that, if he had been, it is likely he would have been sent to hospital.

“I get the impression it would have been more obvious how ill he was,” he told the court.

Recording a narrative verdict, Combes said: “Had he been directed to seek face-to-face or urgent care by the GP practice it is more likely than not that he would have undergone neurosurgery approximately 10 hours earlier than he actually did which, at that time, it is more likely than not would have been successful.”



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