Death of a 'brilliant young man' who was the 'perfect son' could have been avoided, coroner rules

An inquest into a “brilliant” and “talented” 22-year-old from Littleborough has concluded that he died from natural causes but that his death could have been avoided if his cardiac abnormalities had been identified and treatment instigated.

The inquest into Johnny Alfrey’s death took place at Rochdale Coroner’s Court on 5 and 6 January 2023 where evidence was heard from Johnny’s parents, GP, a doctor and cardiologist from the Northern Care Alliance NHS Foundation Trust, and a treating cardiac surgeon from Wythenshawe Hospital.

Coroner Catherine McKenna concluded on 12 January that Johnny’s heart abnormalities indicated the need for an inpatient cardiology referral and, had his cardiac abnormalities been acted upon, then Johnny would not have died in June 2022.

Johnny died on 24 June, just under a month after he originally began suffering from vomiting, shortness of breath and difficulty sleeping.

After his symptoms became worse, he attended the Urgent Care Centre at Rochdale Infirmary where he was diagnosed with a prolonged QTc interval, when the heart takes longer than usual to recharge between beats.

A prolonged QTc interval is seen on an ECG and is a symptom of Long QT Syndrome which can cause fast and abnormal heartbeats. It affects around one in 2,500 people and can cause sudden death.

Johnny also underwent tests which showed an abnormal liver function, although this was not reported at this point.

He was referred to the cardiology team at Fairfield General Hospital but did not attend; his family say he was “reassured that the prolonged QTc interval was benign.”

Johnny was told that Fairfield General Hospital had had an IT outage and that he would therefore be in a hospital corridor overnight and unlikely to be seen until the next day.

However, he attended the A&E department at Fairfield just two days later complaining of heart palpitations, difficulty breathing and vomiting.

An ECG again showed a prolonged QTc interval, but also a T-wave inversion which can be a sign of heart disease.

Doctors put Johnny’s symptoms down to panic attacks, and he was sent home with advice to see his GP as his symptoms were considered to be mental health related.

On 28 May 2022, Johnny returned to the Urgent Care Centre at Rochdale Infirmary with ongoing vomiting and extremely low blood pressure.

Doctors focused on Johnny’s abnormal liver function test results – which had not previously been communicated to him due to the IT outage – and thought he was suffering from hepatitis and/or sepsis.

Johnny was transferred to Fairfield as he had not responded to treatment and continued to deteriorate.

He was admitted to the Acute Medical Unit and an ECG again confirmed a prolonged QTc interval. Doctors continued to treat him for acute hepatitis without considering the urgency of his prolonged QTc heart trace.

Johnny was permitted to leave hospital on 31 May 2022 on the basis that he would undergo blood tests the following day to monitor his condition. Unfortunately his symptoms persisted, and he also began to experience abdominal bloating and pain, plus shoulder pain.

He returned to Rochdale’s Urgent Care Centre on 7 June and was swiftly transferred to Fairfield. By this stage, Johnny’s kidneys were failing, and he was treated for this as well as his liver.

The prolonged QTc persisted and was not acted upon – the family believe this was down to Johnny’s age and a focus on other incorrect diagnoses.

 

 

The coroner heard at the inquest that Johnny was in a very high level of distress and anxiety during his time in hospital. At hospital, Johnny ‘crashed’ and required resuscitation, being put on life support in the Intensive Care Unit.

It was not until the next day that the significance of Johnny’s heart issues were finally considered and he was transferred to Wythenshawe Hospital in a state of cardiogenic shock. He was taken straight to theatre for emergency heart surgery in the cardiothoracic critical care unit.

Tragically, Johnny’s organs continued to fail, and life support was withdrawn on 24 June 2022. A subsequent post-mortem examination indicated that Johnny had died of multi-organ failure caused by acute cardiac failure of unknown cause.

Prior to Johnny’s inquest, Northern Care Alliance NHS Foundation Trust produced an incident investigation report regarding the care provided at Rochdale Infirmary and Fairfield General Hospital.

This report found that Johnny was not referred for a timely cardiology review in light of his cardiac abnormalities and instead the focus had been on his liver problems. An action plan was prepared to address and prevent re-occurrence of the shortcomings identified within the report.

The coroner concluded an inpatient cardiology referral for an echocardiogram during Johnny’s hospital admission from 28 May 2022 would have identified Johnny’s cardiac abnormalities and management via medication would have commenced. Had there been no improvement in Johnny’s condition, then he would have been transferred to Wythenshawe Hospital for surgery.

The inquest heard that these events would have taken place whilst Johnny was still stable, and Ms McKenna ruled had this been the case, that he would not have died on 24 June.

Commenting on the verdict, Julie Alfrey and Chris Charnley, Johnny’s parents said: “Johnny was a good man at the very start of his adult life.

“Amongst many shining attributes, Johnny was a musician, a performer, a lyricist, a comedian, a leader and an intellectual. Our home is much quieter without him and we yearn to have the house filled with his voice and music once again.

“Our lives have been shattered by his loss, forever altered by biased assumptions and a blindness to our concerns.

“We watched Johnny suffer a slow and traumatic death whilst we tried, to no avail, to persuade medics to see the bigger picture… but they were already focused on a ‘best fit’ for his symptoms.

“We want to thank Professor Venkateswaran [the treating cardiac surgeon at Wythenshawe Hospital] and his team for their attempt to save his life at Wythenshawe Cardiothoracic Critical Care Unit. Despite their best efforts, Johnny had suffered irreversible damage over the two weeks he spent in and out of the North West hospitals. We are angry, bitter and bereft. We are broken, much like the system that is the NHS.

“Johnny has many friends who will celebrate him through our music charity work. His university has remembered him with an award for excellence in history in his name. His brother and sister are forever influenced by his values and artistic talent. Johnny has no doubt changed many lives for the better and we will continue to do this for him through his charity and by campaigning for change through our story.

“We continue to be supported by some very caring individuals in the NHS. We would like to thank our bereavement nurse and our family’s GP as well as our counsellors from Cardiac Risk in the Young (CRY) and our legal team.

“We would lastly like to thank all the kind and loving people around us who have made a difference to us in the smallest of ways.”

Mala Patel, associate in the clinical negligence department at Hugh James solicitiors, added: “This is an extremely tragic case which shines a light on how the significant signs of cardiac abnormality were missed and not acted upon in a young man.

“I hope the sad circumstances of this case can result in greater awareness amongst clinicians and a change in practices to prevent re-occurrence of these tragic events in the future. I wish to pay tribute to Johnny’s parents Julie and Chris who have shown enormous strength throughout the inquest process.”