'Missed opportunities' before dad's sudden death

Karl Lee suffered life-changing injuries when he was hit by a taxi in 2008

A coroner said an NHS trust "missed opportunities" to investigate whether a 32-year-old father was suffering from serious muscle relaxant withdrawal before his unexpected death.

Karl Lee - who relied on a baclofen pump to manage pain and spasms after he was hit by a car in 2008 - suffered a sudden cardiac arrest and died at the Queen's Medical Centre in Nottingham in November 2020.

His family were repeatedly told the appropriate checks of Mr Lee's fitted pump were carried out, which an inquest into his death found to be incorrect.

On Friday, a coroner concluded a "relative baclofen withdrawal" and a serious reaction to medication were the underlying causes that led to Mr Lee's death.

Mr Lee's loved ones said they waited five years to get answers from Nottingham University Hospitals NHS Trust

Mr Lee's family said they had waited five years to get answers from Nottingham University Hospitals NHS Trust about what happened to him.

The father of one - from Clifton - was registered disabled after he suffered life-changing injuries in the road incident, and family members became his carers.

Mr Lee was left with damage to his knee, which led to a diagnosis of a chronic pain condition called complex regional pain syndrome.

He continued to suffer from pain and spasms and was subsequently fitted with an intrathecal baclofen pump (ITB) - which delivered the relaxant into his spinal fluid and had to be periodically refilled.

Mr Lee had his right leg amputated above the knee in 2013.

Mr Lee left behind a close family, including his wife Sammie and their baby boy when he died

When he was admitted to hospital on 16 November 2020, with continuing spasms, increased pain and a high heart rate, Mr Lee's family raised concerns he could be having a baclofen withdrawal, the inquest heard.

Assistant coroner Elizabeth Didcock said the possibility of a baclofen withdrawal was not appropriately assessed "as it should have been", either during Mr Lee's hospital admission or after he died.

That means the conclusion of a "relative" baclofen withdrawal refers to an increased need for the muscle relaxant at the time Mr Lee died, rather than any issues with his device.

The inquest - at Nottingham Coroner's Court - heard during Mr Lee's hospital admission, a referral was not made to the neurosurgical team, whose care he had been under for several years.

Although a nurse from the team did visit him, she did not check his baclofen device or assess his notes, and instead, relied on how he was presenting to her at the time.

Despite this, a neurosurgical consultant wrongly stated the necessary checks of the pump were carried out.

That statement, which formed part a response to the family's complaint about Mr Lee's care, also led to a coroner initially deciding an inquest was not required.

It was because of that, the family took their complaint to the Parliamentary and Health Ombudsman, which found no evidence Mr Lee's pump was checked and finally led to an inquest opening in September.

'Years of hell'

Following the two-day inquest, Ms Didcock said she "could not imagine how difficult this has been for the family" and extended her condolences to Mr Lee's family and friends.

She added regarding the conduct of [the neurosurgical consultant], she had requested to see his earlier statement to "more fully understand" his explanation of the mistakes made.

Mr Lee's widow, Sammie Lee - of the misinformation her family had heard - said: "Because we knew all along [his pump] wasn't checked - it was bittersweet - it was a bit of relief."

His mother Tracy Lee said her family had endured "five years of hell" waiting for his inquest.

"I still cry now. I still cry at night," she said.

"I'm so angry with the trust because of how they've said things and they've been untrue - and that impacts on us greatly.

"Five years of fighting this case has really taken it's toll on us. We didn't need that. We really didn't."

Mr Lee - whose son was a baby when he died - was described by his family as a "compassionate and deeply principled" man.

Following the inquest, Manjeet Shehmar, medical director at NUH said: "We accept the findings given by the coroner and recognise that there were missed opportunities in Karl's care, for which we are very sorry.

"We have carried out investigations and changes have been made, including an alert on patients' records with an intrathecal baclofen pump to contact the neurosurgery team if they are admitted to the trust for treatment.

"We have also updated and improved the complaints procedure, and are in the process of updating the clinical guidelines."