A university student died after doctors failed to spot a head injury he sustained during a night out to celebrate his birthday because they assumed his condition was due to excessive drink, a coroner has found.
Maria Voisin, the senior coroner for Avon, said the death of 22-year-old Alex Green was “contributed to by neglect” by hospital staff.
Green, an economics student at the University of Bath, was discovered unconscious at a bus stop in the city in the early hours of 30 September 2017.
Both paramedics and doctors at the Royal United hospital in Bath failed to diagnose a “spectacular” internal head injury, the inquest heard.
The damage – including a fractured skull – was only spotted when Green suffered a respiratory arrest 10 hours after being admitted to the hospital. He was transferred to Southmead hospital in Bristol, but died there three days later.
Following a five-day inquest at Avon coroner’s court, Voisin found a number of gross failures that “caused or significantly contributed to Alex’s death”.
She concluded that the death of Green, from East Molesey, Surrey, was an “accident contributed to by neglect”.
Voisin said: “There was an assumption by everyone managing Alex that he had been intoxicated when in fact, he had a significant head injury.”
The coroner identified five failings with Green’s care, including the assumption that his reduced consciousness was due to intoxication with “no corroborating evidence”. She also said Green was not seen by a doctor for three hours and was not managed properly after falling from his hospital bed.
“There was also a gross failure to provide basic medical attention which Alex obviously needed,” Voisin said.
Friends told the hearing they had surprised Green with a birthday celebration in Bath on the evening of 29 September. In the early hours next morning he was discovered unconscious in the city centre by another group of students. It is not clear how he sustained the head injury. The inquest at Flax Bourton, near Bristol, heard he may have fallen or been hit by a car.
Speaking after the hearing, Green’s parents, David and Karen, described him as “wonderful, bright, beautiful and kind”.
“Our grief is overwhelmingly painful every day,” they said. “As a family, we are shocked and appalled by the lack of care given to Alex by both the South West Ambulance Service and the Royal United hospital.
“Alex was in their care for over 10 hours, with a serious but detectable and treatable head injury which was not properly considered and never diagnosed.”
The Royal United Hospitals Bath NHS Foundation Trust said it extended its “sincere sympathy and apologies” to Green’s family and friends.
Bernie Marden, its medical director, said: “We will now reflect on the coroner’s findings and act on the further learning opportunities identified.”
The ambulance trust has been asked to comment.
