Richard Coxall Died At Work As Paramedics Battled To Breach Locked Doors

The family of a school caretaker who died at work after an asthma attack have received a settlement after staff at his GP practice admitted they failed to properly manage his respiratory symptoms.

Richard Coxall died after calling 999 from Townley Primary School in Christchurch where he was working alone during the half-term break. Paramedics quickly arrived at the scene, but despite being able to see the stricken 48-year-old, they could not reach him because the building’s doors were locked.

Michelle, Richard’s wife, instructed expert medical negligence lawyers at Irwin Mitchell, to investigate her husband’s care under George Clare Surgery in Chatteris, Cambridgeshire which Richard visited 11 times in the six months prior to his death on April 11, 2011. His last appointment was just two days before his death.

The firm discovered that, despite having a history of asthma in childhood and again in 1998 when he was 35 recorded in his medical notes, one practice nurse wrongly recording a history of Chronic Obstructive Pulmonary Disease meaning he did not receive the correct long-term care.

Throughout his treatment, Richard was prescribed antibiotics and several different steroid inhalers for short-term use. He also was treated with a nebuliser on a number of occasions after calling the out-of-hours service with breathing difficulties, after which his condition briefly improved.

This, medical experts for Irwin Mitchell say, should have indicated to doctors that the father-of-three was not suffering with COPD, but severe asthma.

The firm say Richard should have in fact been prescribed continuous steroid inhalers from which he should have been advised to take a minimum dose of two puffs a day. This, the experts say, should have been taken alongside a Salbutamol inhaler; a medication that opens up the medium and large airways in the lungs. 

Anna Stacey, an expert medical negligence lawyer at Irwin Mitchell, representing Michelle, said: “Richard and his family did everything they could to reduce his breathing difficulties, from Richard giving up smoking to re-homing the family cat which had just had a litter of kittens. But his health did not change.

“Michelle is still reeling from her husband’s sudden death and his loss has resulted in significant distress among their children, one of whom is too frightened to play in the garden in case her mum has disappeared “like daddy did”, when she returns.

“Richard was also the sole provider for the family, and his loss created a terrible situation whereby Michelle was at home caring for her young daughter while her 17-year-old daughter went out to work to support the family.

“While no amount of money will ever takeaway the pain and distress of losing Richard, we are pleased that the family can now be provided for so they can focus on supporting each other without the worry of mounting debt.”

Richard met Michelle in 1978 when he was 17-year-old and she was just 13. The couple married five years later and in 1994 welcomed their first daughter, followed later by a son and a second daughter, who was just six when she lost her father.

On the day of his death Michelle called her husband to arrange to pick him up from work at 2.30pm to take him to a doctor’s appointment. But when she arrived the entrance was surrounded by police cars and a private ambulance.

The cause of Richard’s death was recorded as cardiac arrest due to cardiac arrhythmia induced by breathing problems caused by acute severe asthma.

After learning of Richard’s death from the school’s head teacher, Michelle was told that paramedics had had to call police to break down the door to get to Richard but, despite the best efforts of the emergency services, by the time they reached him it was too late.

Michelle, 50, said: “The one person I want to talk to the most is the person who isn’t here anymore and this realisation hits me every day. I have to hold it together for the sake of my children, but there are times when I feel very alone.

“Nothing can ever make this better, but by talking about what happened to Richard I hope lessons will be learned which prevent any other family going through what we go through.

“Richard would have been alive today with the correct care. There were so many opportunities missed in the months leading up to his death and I hope by taking legal action those involved will have sat up and taken notice of the risks to patients presenting with undiagnosed respiratory illness.

“Put simply, I hope lives can be saved.”

 Read more about Irwin Mitchell's work in medical negligence claims, here.