A CORONER has blamed a series of failures at an NHS walk-in centre for contributing to the death of a kick-boxer, who died from swine flu.

Mark Mason, 36, died less than 24 hours after being sent home by a doctor at the centre in Rotherham.

Mark, from Winston Avenue in Newton-le-Willows had been in bed for a week, wasn’t eating or drinking and had diarrhoea. He couldn’t walk unaided and was struggling to breathe when he turned up at the centre in 2010, an inquest in Sheffield heard.

Although his oxygen blood saturation levels were found to be abnormally low, the normally superfit kick-boxer wasn’t given oxygen or admitted to hospital.

After Mark’s death, on Dec 16, 2010, GP Dr Ali Kouchouk was suspended by privately run health care provider Care UK, which runs the Rotherham NHS Walk-In Centre pending an internal inquiry, but was reinstated as an out-of-hours doctor.

An expert consultant in emergency medicine Dr Alan Fletcher told the hearing that if Mark had been given immediate hospital treatment, he would have survived longer but he could not say if he would have lived.

Recording a narrative verdict, Sheffield coroner Chris Dorries identified four failures as “more likely than not contributing to the death of Mr Mason.”

He highlighted a lack of training for a triage nurse, failure to communicate important information between nurse and doctor, a failure to check the low sats levels and the omission of the low sats reading in the patient assessment.

The inquest heard nurse practitioner Michelle Jackson-Smith had worked as a triage nurse assessing patients for only a month and had not been trained in the job. During a five minute examination of Mark, her pulseoximeter, which measures oxygen saturation levels of blood, gave a reading of 62 per cent. Below 92 per cent is considered serious.

The nurse believed her equipment was faulty and did not check the accuracy.

Although she said Mark was one of the “sickest cases” she had seen, instead of walking a few yards along a corridor to the consulting room to speak to the doctor, she flagged up Mark’s case on the GP’s computer. Mr Dorries said this lack of direct communication with the GP was another serious failure.

Dr Kouchouk, who comes from Iraq and has been a GP here since 1982 said he was unaware at the time that there was a system for flagging up patients on the screen as “high priority”.

He was “concerned” for the patient because he was unwell and had no treatment for a week but did not feel he was seriously ill.

Mark, who had been working in Yorkshire as a contractor was seen at lunchtime on Wednesday, December 15, 2010, but was found dead by his father Geoff at 11am the next day in a Barnsley bread-and-breakfast.

The cause of death was adult respiratory distress syndrome, due to swine flu.

Dr Fletcher told the hearing that Mark would have been showing early signs of swine flu 24 hours before his death: “If I saw those features in hospital, on balance I would have not sent him home.”

Asked by the coroner if he would have survived had he gone to hospital, Dr Fletcher said the treatment for Mark’s condition was “challenging” but added: “I’m not in a position to say his death was avoidable.”

Mark’s brother Chris said Dr Kouchouk gave him a “general invitation” to go to hospital three times, but Mark declined as he didn’t want to be away from work.

  • Since Mark’s death, the Rotherham Walk-In-Centre has introduced a new system for flagging up seriously ill patients to doctors, formal induction programmes for staff and a training programme for triage nurses.