Southampton hospital 'should revisit patient's death'

Hampshire coroner Rosamund Rhodes-Kemp spoke out at an inquest into the death of engineer Nicholas Ginger, who was having a video consultation with an agency nurse when he disappeared from her screen.

Mr Ginger, a 65-year-old father of three from Shirley, worked for University Hospital Southampton NHS Foundation Trust.

He was discovered unresponsive at his home about six hours after the video call ended and was found to have suffered a bleed on the brain.

Members of Mr Ginger's family outside Winchester Coroner's Court, where the inquest was held (Image: Newsquest)

The three-day inquest was attended by his daughter, Maria Burgess, who criticised what she described as "missing evidence and contradictory reports" surrounding his death.

Mrs Rhodes-Kemp added: "The investigation was, perhaps, not as co-ordinated as it could have been. I've never come across anything like this in more than 30 years."

She referred to statements made by the nurse, Jackie Chatterton, when she sought to explain why Mr Ginger disappeared from her screen and whether or not an ambulance should have been called.

READ MORE: Online nurse tells inquest she should have called an ambulance after patient disappeared from her screen

Mrs Rhodes-Kemp said it was "completely impossible to reconcile the various strands of evidence" given by the witness.

Earlier, the coroner said she was struggling to summarise all the information given to the inquest, adding: "I've never known anything quite as perplexing."

Nicholas Ginger held a managerial role at University Hospital Southampton. He was an electrical engineer by trade (Image: Newsquest)

Mr Ginger had a long and complex medical history, with a raft of conditions that included chronic heart disease and high blood pressure.

The video consultation took place on the morning of November 30, 2022.

After he vanished from her screen Mr Ginger told Miss Chatterton that he was all right. But she was sufficiently concerned to send a Teams message to her line manager, Christine Lawrence.

However, the message never arrived - and no ambulance was sent.

The inquest heard that Mr Ginger was found slumped on his sofa by one of his two sons at around 5pm.

He was rushed to the neurological intensive care unit at University Hospital Southampton. But his family were warned he was unlikely to survive and he passed away on December 2.

Mrs Rhodes-Kemp recorded a conclusion that he died of natural causes.

She said the Trust should "revisit" its investigation into his death and provide her with written confirmation that it will do so. She also said his family should be given a copy of the final report.

After the hearing, the family issued a statement that referred to Miss Chatterton and Ms Lawrence.

The statement said: "Mrs Rhodes-Kemp was incredibly thorough and compassionate.

"An inquest is never allowed to be accusatory, but she made very fair comments about not being able to reconcile the very contradictory statements given by the two nurses.

"She said things 'didn’t stack up' and she has never come across anything quite like this in over 30 years in her role. 

"It is reasonable to say that Dad had been unwell for four months and that his health declined ahead of his death, but I am still shocked by the inaction of the nurses.

"It is appalling that NHS professionals can make such outrageously differing accounts.

"My Dad was a wonderful family man who felt he made a difference in the NHS every day. When he needed them most, I feel he was so badly let down."

The statement called for more action from the Care Quality Commission, which regulates the health sector.

"The hugely insufficient internal investigation conducted (and retrospectively now ordered to be redone following this inquest), highlights the need for external involvement in safety reviews and potential wrongdoing."

A spokesperson for University Hospital Southampton added: "We are deeply saddened by the death of our valued colleague and our thoughts and sympathies remain with Mr Ginger’s family. 

“The circumstances surrounding Mr Ginger’s death were investigated and reviewed, and as a result we have introduced a series of improvements to our occupational health processes and guidance, which have also been shared with our healthcare partners across our system.

"Following today’s inquest, we will be sharing an updated report of our findings with Mr Ginger’s family."