Shropshire man's death 'was preventable after wrong diagnosis by locum doctor'

The death of an Oswestry restaurant manager could have been prevented if not for a missed diagnosis by a locum doctor in Shrewsbury, a coroner has ruled.

Alan Spencer Busby died aged 69 on June 30, 2019 at Royal Stoke University Hospital after emergency surgery for acute subdural haematoma – a blood clot on the brain.

The operation came after Mr Busby collapsed at his home days earlier, when he was then taken to Royal Shrewsbury Hospital (RSH).

Mr Busby was later released from A&E with a diagnosis of vertigo from locum health worker, Dr Vytautas Liesis.

Originally, Mr Busby's death was ruled as natural causes by a coroner in Stoke, but following an investigation sparked by Dr Adrian Marsh from RSH, the case was transferred to Shropshire and Telford & Wrekin senior coroner, John Ellery.

At the hearing on Thursday, October 22, the court heard from Dr Liesis, as well as Dr Marsh and Dr Alexis Jones, who both told the inquest that Mr Busby had been misdiagnosed.

Dr Jones and Dr Marsh told the court that they both would have ordered a CT scan on Mr Busby, but Dr Liesis argued that Mr Busby gave no symptoms that would require a scan to be conducted.


However, on Thursday, October 29, Mr Ellery agreed with Drs Jones and Marsh in his conclusion that Mr Busby's death was preventable.

Mr Ellery said: "Alan Spencer Busby attended the emergency department at the Royal Shrewsbury Hospital via ambulance on June 25, 2019, after an episode of collapse at home.

"He had a two-day history of headache with neck stiffness, off his legs, vomiting and unsteady when standing.

"Following an assessment by the emergency medicine locum registrar, he was diagnosed as having benign positional vertigo and discharged home.

"He subsequently deteriorated, requiring readmission the following morning. Following a CT scan he was then transferred to Royal Stoke University Hospital where he underwent emergency surgery, but sadly died four days later.

"An appropriate assessment and diagnosis of Mr Busby's condition on the evening of the June 25, 2019 would have led to a CT scan being performed and that in turn would have led to an earlier transfer to, and surgery at, Royal Stoke University Hospital – with either a complete or partial recovery and at its lowest, not dying when he did."

Mark Cheetham, care group medical director at the Shrewsbury and Telford Hospital NHS Trust, which runs RSH, said: “Our priority is to deliver the best possible care to all of our patients. We wholeheartedly apologise to the family of Mr Busby that this did not happen on this occasion.

“A full investigation, involving the coroner and other relevant authorities, has been carried out into this sad and tragic incident.

"Our thoughts remain with the family of the patient. We have also carried out our own internal investigation and taken actions to address the failings in this sad case.”

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