Coroner criticises medics after death of Milton Keynes man, 37, who was suffering from a sore throat

A 37-year-old MK man died two days after being sent home by the city’s Urgent Care Centre with a throat infection.

Doctors missed the fact that Leonard King was suffering from acute epiglottitis, an infection of the epiglottis and surrounding tissue that has potential to cause a sudden, complete and fatal obstruction to the airway.

And, later the same day, when an ambulance was sent to Mr King’s home via a 999 call for help, paramedics also missed the fact that he was in danger.

He died two days later after collapsing with a hypoxic cardiac arrest, because the epiglottitis had blocked his airway.

Now, following an inquest, assistant MK coroner Sean Cummings has written a Prevention of Future Deaths report and sent it to the bosses of Urgent Health UK as well as the Association of Ambulance Chief Executives, Royal College of Emergency Medicine and the Royal College of General Practitioners.The report states: “During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.”It explains that acute epiglottitis was mainly confined to young children before the introduction of the Haemophilus Influenzae (Hib) vaccine, which is routinely given to babies from two months of age.“Subsequent to mass immunisation the demographic has changed and more adults are developing epiglottitis,” it states.

“It is not common in this group but because of the expectation among clinicians that it is a still a disease of children, there is a tendency, except in those routinely dealing with acute emergencies of the airways, to regard typical symptoms as those of a sore throat or tonsillitis and not as the harbinger of sudden catastrophic obstructive epiglottitis.”The report adds: “The disease classically develops rapidly in children but in adults may take several days which may be falsely reassuring. Typical symptoms may include a sore throat which becomes more severe with time, difficulty swallowing secretions, pain on swallowing and an alteration in voice.

"Prompt recognition and treatment is lifesaving.”

The report continues: “There was a missed opportunity to recognise and escalate his case at the Milton Keynes Urgent Care Centre on the 2nd May 2022. There was a further missed opportunity by South Central Ambulance Service when they were called via 999 to his home... later that afternoon, to recognise the fact that he was in a precarious position and removing him to the ED.

"This was an avoidable death.”The recipients of the report have to respond within 56 days, giving details of what action will be taken.A spokesperson for South Central Ambulance Service (SCAS), said evidence was heard in court on the rarity of the infection and at the time Mr King was assessed he did not present as needing hospital treatment.

They said the trust was "committed to learning” from such cases.

A spokesperson for the Urgent Treatment Centre said Mr King was given an "appropriate and comprehensive examination".

They added: "After Mr. King's death, and prior to the inquest, we committed to provide education to our clinical staff about this rare presentation in adults. We continue to educate and support our staff and endeavour to co-ordinate this learning with other healthcare providers.”