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Patient dubbed 'the invisible man' by a coroner was ignored by hospital doctors for three DAYS before he died
Walter Coles, 88, was transferred to Wycombe Hospital last summerBut senior doctors were unaware of his arrival and his care was 'overlooked'
The only documentation of his stay 'verged on useless', an inquest heardAs well as not being examined, his medication chart went missing
Mr Coles been transferred there from Stoke Mandeville Hospital, Aylesbury, three days earlier.
Walter Coles died at Wycombe Hospital, Buckinghamshire, last summer. His care was 'substantially overlooked' and senior doctors were unaware of his arrival, an inquest heard
The inquest heard that a catalogue of errors occurred with Mr Coles' care.
As well as not being seen by a doctor, registrars were not told of his move and his medication chart went missing – before being filled out again by a doctor who hadn't examined him.
Coroner Richard Hulett ruled that Mr Coles, of Quainton, Buckinghamshire, died of natural causes, but added the 88-year-old had been 'substantially overlooked' while he was under the care of Wycombe Hospital.
And he said the lack of evidence over what had happened was 'verging on the useless' for staff tasked with investigating the circumstances surrounding Mr Coles' death.
Mr Coles did not arrive until around midnight of Friday 6 into Saturday 7 July, but Dr Thomas Chapman, the on-call registrar, was not told of his admission – which meant protocol to have him medically reviewed was not carried out.
Dr Chapman told Beaconsfield Coroner's Court: 'I can be absolutely certain I wasn't informed of his arrival. It could have been escalated to night manager or the consultant on call. There's no record of that.'
The registrar on-call during the day, who was unable to be identified, knew of Mr Coles' imminent transfer but went off duty at 5pm and neglected to tell the person replacing them. This meant news of his arrival was not subsequently passed on to Dr Chapman.
Mr Coles had been transferred from the Stoke Mandeville Hospital
Mr Hulett said: 'There's no evidence the appropriate doctor at Wycombe on the late afternoon shift knew Mr Coles was coming.
'There was a responsibility for the nurses in charge to report this late arrival to the duty registrar. That didn't take place.'
At some point on Saturday Mr Coles' drug chart went missing and a replacement was produced by Dr Thomas Morgan based on his medical notes.
But Mr Hulett said: 'He never saw the patient, never reviewed him at all and never raised the question, “Has anybody looked at this patient”.'
Nurse Faith Tamangani told the inquest she could recall having a telephone conversation with a doctor about Mr Coles but could not remember who she spoke to, nor could she recall reporting his arrival to Dr Chapman.
As well as not being seen by a doctor, registrars were not told of Mr Coles' move and his medication chart went missing (stock photo)
Mr Hulett said in his summing up that 'record keeping and communication were poor' and the doctor referred to by Nurse Tamangani was 'not identified and completely unidentifiable'.
He added: 'What was recorded was verging on the useless – it made impossible for those who came to enquire to identify the doctor and say to that doctor, “Why did nobody do anything or attend the patient”'
The coroner recorded Mr Coles died of natural causes but added: 'Although he does succumb to this and he does die of a medical cause, he becomes the invisible man of that ward.
'The fact somebody died and would have done so is no excuse for being substantially overlooked while they are in an NHS hospital.'
Lynne Swiatczak, Chief Nurse and Director of Patient Care Standards with Buckinghamshire Healthcare NHS Trust, said after Wednesday's inquest: 'We would like to express our deepest sympathies to the family of Mr Coles.
'We carried out a thorough investigation into Mr Coles' care, which identified that standard Trust processes were not always followed.
'We have taken, and continue to take, action to strengthen the processes we have in place, including documentation and re-training staff on record-keeping and communication. The coroner indicated that lessons had been learned at the Trust since Mr Coles' death.
'We will take the time to reflect on what was said at the inquest. While Mr Coles died of natural causes, as reported by the coroner, we will of course consider what further action we can take to learn from this.
'The Trust is committed to providing excellent patient care and ensuring patient safety.'