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One dogged coroner, four needless deaths and a stark conclusion: the NHS is broken

When David Morganti’s case notes landed on Andrew Cox’s desk this autumn they told a devastating story — but one which was depressingly familiar to the senior coroner for Cornwall.

The 87-year-old RAF veteran had fallen and hit his head in the bathroom of the house he shared with his wife, Valerie, in April. It took nine hours for paramedics to reach their home near St Austell, Cornwall. As they waited, the bleeding on his brain became gradually worse until he lost consciousness. By the time he reached hospital it was too late. An expert neurosurgeon told Cox that had he reached hospital faster, Morganti might have survived.

The coroner said the effects of the injuries he suffered were likely to have been exacerbated “by a delay in the arrival of an ambulance and his subsequent admission into hospital.”

It was the latest in a series of similar deaths the coroner had encountered. 

After Morganti’s inquest, Cox resolved to carry out a wider investigation into what appeared to be a broken system. He has now sent his findings to Steve Barclay, the health secretary, and demanded he act to prevent more deaths.

Read full story (paywalled)

Source: The Times, 19 November 2022


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