A talented musician suffering a pulmonary embolism was sent home with antibiotics – days before returning to A&E and dying as he waited 10 hours to be seen.
Ellis Thompson, 31, a graduate of Royal Northern College of Music, was a gifted classical musician who taught violin and piano but attended Manchester Royal Infirmary (MRI) in May 2022 feeling unwell.
An inquest at Manchester Coroner’s Court heard Ellis was suffering a deadly embolism but medics misdiagnosed it as a chest infection and he was sent home with antibiotics.
However still unwell, Ellis returned to the MRI two days later and while waiting hours to be seen he collapsing and tragically died on the morning of 17th May.
On Tuesday, Coroner Zak Golombeck concluded: “There was a failure in Ellis’ care that more than minimally contributed to Ellis’ death.”
The hearing was told how Ellis, originally of Gloucestershire, first attended MRI’s A&E on 14th May 2022 after suffering with shortness of breath for five days.
A doctor carried out an assessment which included a check in his calves for thrombosis – a check which normally suggests a suspicion of pulmonary embolism.
But despite insufficient evidence to rule it out Ellis was diagnosed with a lower respiratory tract infection and discharged with antibiotics.
In his ruling, Mr Golombeck said that the doctor “must have had enough suspicion about a pulmonary embolism to undertake an examination of his lower limbs.”
Two days later on 16th May, Ellis returned to the MRI at 9.15pm and was triaged as a ‘yellow’ category, meaning he should have been seen within an hour.
His inquest concluded he should have been classed as ‘orange’, meaning he would have been assessed by a clinician within 10 minutes.
Instead, Ellis waited for nine hours and 45 minutes before collapsing at 7am on 17th May. He passed away from a cardiac arrest brought on by pulmonary embolism.
Ellis had been waiting for medical attention in a temporary waiting room, which at the time was a heated marquee attached to the main Accident and Emergency waiting room.
This was to allow for social distancing during the coronavirus pandemic, in line with NHSE guidelines. The coroner said had his embolism been spotted earlier on his first visit, treatment may have been effective.
Tragically, by the time Ellis returned to A&E on 16th May, Mr Golombeck found there was only small possibility his death could have been avoided.
The MRI’s consultant in emergency medicine Dr Alan Grayson explained that when Ellis first arrived, his symptoms would not be enough to lead to a diagnosis of pulmonary embolism.
He claimed: “There are lots of features that are not specific. These signs do occur on people with pulmonary embolism, but they occur on people with lots of other conditions as well.
“I would want the doctor to come up with a range of diagnosis and treat the most likely thing.”
However the coroner rejected this, arguing how the check on Ellis’ calves on 14th May indicated already a blood clot and pulmonary embolism concern.
Mr Golombeck added: “This was present and should have been diagnosed and treated during the deceased’s first presentation.”
MRI was also criticised over the long wait times which saw Ellis having to wait nearly 10 hours despite being triaged as a urgent case.
Dr Grayson told the court: “He should have been seen earlier than he was. We got that wrong and that’s an error on our part.”
Reaching a narrative conclusion, Mr Golombeck said: “The deceased died from natural causes, with his death contributed to by a decision to discharge him without full and proper investigations, which had they been carried out would have led to a diagnosis of pulmonary embolism and appropriate treatment.”
A spokesperson for Manchester University NHS Foundation Trust said: “We would once again like to offer our condolences to Mr Thompson’s family following his sad death almost three years ago, when COVID 19 guidance was still in place.
“The Trust will carefully study the Coroner’s findings to identify and implement any further learning.”