The fiancee of a man who died in hospital during stroke treatment said her concerns about his worsening condition were dismissed by medics.
Holly Renfrew said she urged staff at the Queen’s Medical Centre (QMC) in Nottingham to operate on her partner Gordon, 36, but they did not act until it was too late.
The trust that runs QMC has apologised to Ms Renfrew.
The couple, from Aberdeen, were visiting Ms Renfrew’s family in Branston, Staffordshire, to shop for a wedding dress in June 2022 when he suffered a severe stroke.
Mr Renfrew, a software engineer known to his loved ones as Rene, was taken to the QMC on 7 June where he had surgery to remove a blood clot but he remained very ill.
He underwent a decompression craniectomy – surgery to reduce pressure caused by brain swelling – on 10 June but he died four days later.
Nottingham coroner Dr Elizabeth Didcock, who carried out Mr Renfrew’s inquest, said the QMC’s stroke team had not understood or followed National Institute for Health and Care Excellence (NICE) guidelines which should have triggered discussions with his family on 8 and 9 June about the craniectomy he needed.
The coroner said: “Had this occurred it is very likely that the procedure would have been performed at an earlier time, although it is not possible to say, on a balance of probability, that this would have led to Gordon surviving what was a very severe and extensive stroke.”
Dr Didcock also concluded QMC’s stroke team and the neurosurgery team had not communicated well enough about Mr Renfrew’s treatment and warned patients could die in the future if the problems were not solved.
She has sent a report to Nottingham University Hospitals (NUH) NHS Trust setting out concerns she identified.
NUH has until 31 August to set out actions it will take to address issues she raised.
Ms Renfrew said her fiance was moved to the stroke ward between his operation but that he should have been kept under closer observation in ICU.
“I stayed with him in the hospital, I sat with him, I read to him and talked to him.” she said.
“I’d been told to look out for certain signs, like him drifting off more frequently when I was talking to him or when his monitoring checks were being performed.”
She said he deteriorated on 9 June and she immediately alerted staff, but the surgery did not happen until the following day.
“I told a doctor I thought he was getting worse but my concerns were dismissed,” she said.
“He said I was emotional and he was professional and that they were monitoring him.
“I was shocked that he came out with that. Aside from the fact he was insulting, he was wrong.”
Missed opportunities
“Gordon was a kind, fun loving and driven person. He had a great zest for life and a caring, generous and cheerful nature.
“He was always thinking of others, always putting me first.
“Even in the hospital following his stroke and surgery I could see him trying not to worry me. Seeing how he acted with absolute selflessness, love and bravery in such a time filled me with complete awe and is testament to the man he was.
“Nothing will bring Rene back, but I don’t want the same issues to be repeated and for someone else to lose their life as a result.
“I’m grateful that the coroner produced a prevention of future deaths report and hope this brings about the changes required.”
NUH medical director Keith Girling said: “The trust continues to reflect on Mr Renfrew’s care and we would like to apologise to Holly if she did not feel she was listened to when raising her concerns.
“We do acknowledge that there were missed opportunities for earlier consideration of decompressive craniectomy as per national stroke guidance and whilst the coroner could not determine that this would have prevented Mr Renfrew sadly passing away, we are very sorry for this.”
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