BackA family is a step closer to getting answers to why Karl Lee, a father from Nottingham, died while in hospital, after an Ombudsman investigation compelled a coroner to carry out an inquest into his death.
Karl, 32, died after staff at Nottingham University Hospitals NHS Trust failed to recognise the signs of pain medication withdrawal, despite knowing his reliance on baclofen. If they had acted correctly, properly diagnosed and treated his symptoms, he might have survived.
Karl had severe pain in his knee caused by a road traffic accident. In 2011 he had an intrathecal baclofen (ITB) pump and a spinal cord stimulator implanted into his abdomen. Baclofen is a muscle relaxant and an ITB delivers the medication directly into the spinal fluid. He regularly visited the Trust’s neurosurgery team for refills and maintenance of his baclofen pump.
In 2020, he was admitted to hospital with symptoms including excessive muscle spasms, shivering, confusion and hyperventilation. Staff initially suspected sepsis and administered antibiotics. The symptoms of baclofen withdrawal and sepsis can be similar, yet staff who were familiar with Karl’s dependence on the medication failed to fully investigate his symptoms and consider baclofen withdrawal as a possibility. Had they done so, they could have treated him and potentially saved his life.
Karl’s mother Tracy and his partner Sammie called for an inquest after the Trust’s own investigation failed to consider baclofen withdrawal - which can be fatal if not treated. His family argued that the Trust’s investigation was flawed because the pump in Karl’s abdomen that administered baclofen had not been checked to see if it was working properly.
A coroner initially ruled out an inquest based on the Trust’s report, which stated the pump had been checked and was ‘perfectly functioning’. This is also what the Trust told Tracy and Sammie when they initially complained. An investigation by the Parliamentary and Health Service Ombudsman (PHSO) found no evidence that it had been checked.
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Source: The Parliamentary and Health Service Ombudsman (PHSO), UK
