Robert Hart inquest verdict
The inquest into the death of Robert Hart, who died after being punched at the Parklife festival in Manchester, has concluded that he was unlawfully killed.
The coroner noted that hospital failures at Salford Royal did contribute to his death, but went on to say that they didn’t amount to neglect.
The five day hearing has heard from 39 witnesses.
Coroner Nigel Meadows recorded:
'At about 21.18 hours on the 7 June 2014 the deceased (Robert Hart) was attending the Parklife Music Festival in Heaton Park, Manchester, when he was unlawfully assaulted by a male person who hit or punched him one or more times. He fell to the ground and was rendered unconscious for a period of about five minutes. He received CPR from members of the public and was sucessfully resuscitated. After a few minutes he was able to stand up and then received immediate first aid assessment and was taken by ambulance to North Manchester General Hospital arriving at about 22.00hrs. He was triage assessed and seen by a doctor in the minors unit before being admitted to the Clinical Decisions Unit for neurological observations overnight. On the 8 June 2014 shortly, after 09.00hrs, an Emergency Medicine Consultant reviewed him and arranged for him to have a head CT Scan. This was initially reported at about 10.40hrs verbally by a Radiologist as showing significant sub dural and sub arachnoid haemorrhage. The deceased (Rob Hart_ who had been complaining of a persistent and worsening headache was moved to the resuscitation area of the Emergency department and within a few minutes his Glasgow Coma Score dropped to 7. He had to be intubated and ventiliated and prepared for transfer. This was considered to be a serious and life threatening injury and at about 11.00hrs attempts were made to contact the on call Neurosurgical Specialist Registrar for advice and to arrange for his urgent transfer to the regional specialist neurosurgical unit at Salford Royal hospital. Contact was not made until shortly after 12noon when the patient was accepted for transfer but this was cancelled at some time between about 12.15 and 12.30hrs. Some time after 14.00hrs the Neurosurgical Consultant on call was contacted and was able to review the CT Images and noted a life threatening sub-dural haemorrhage and requested that he be transferred urgently. He was admitted at about 16.00hrs and taken straight to theatre for emergency brain surgery. Despite this his condition deteriorated and it was recognised that he had suffered serious irreversible brain damage and he was prounced brain stem dead on the 11 June 2014 at 15.58hrs'.
Mr Meadows concluded:
'The deceased was Unlawfully Killed, but that there was a failure to provide timely and appropriate access to advice from wither a Neurosurgical Specialist Registrar or an on-call Consultant, and a significant failure to adequately and appropriately interpret the CT images, which contributed to the death but such did not amount to a Novas Actus Interveniens.'
The man responsible for the assault has yet to be caught.
Speaking outside court Robert’s dad said: “Considering all the sophistication of electronic equipment, I think we would have been better served with two cans and a length of string.
“The total breakdown – two people couldn’t speak to each other and it cost Robert his life, that’s unforgiving. I cannot forgive those mistakes.”
LISTEN: Our Chief Reporter Michelle Livesey speaks to Robert's mum Elaine after the inquest:
Salford Royal’s Medical Director Dr Pete Turkington said: “We once again offer our deepest sympathies to Robert’s family for the loss of their much loved family member.
“Salford Royal has investigated the circumstances leading up to and following Robert’s transfer to Salford Royal from North Manchester General Hospital and we shared this information at the outset in person with Robert’s family.
“The review into Robert’s care at Salford Royal highlighted that he did not receive the high standard of care we always pride ourselves on delivering and we have apologised unreservedly to his family for this. Robert’s family have had the opportunity to fully express their concerns about his care at Salford Royal and we believe we have addressed these concerns.
“Following a full and detailed inquest, we were reassured that the coroner accepted the improvements we have implemented as a consequence of our investigation and that he ‘could not add anything of substance’ to the changes we have already made.
“We will continue to provide Greater Manchester Police with any information they require as part of their ongoing criminal investigation.”
The family went on to thank their solicitor Zak Golombeck, of Slater and Gordon, and will now be pressing ahead with legal action against the Hospitals involved.
Zak's been speaking to our Chief Reporter Michelle Livesey about the next steps: