A Northampton man bled to death from a rare dialysis complication while being transported to hospital by a volunteer ambulance driver.
X Rokeby - formerly known as Ian Campbell before he changed his name by deed pole - died after a complication with a blood vessel, which had been surgically altered to make dialysis easier, caused him to bleed excessively on his way to an appointment at Kettering General Hospital.
His driver, who had only a small amount of first aid training, tried to stop the bleeding and called the emergency services, but they were unable to resuscitate him.
During an inquest into the death of Mr Rokeby - of Gurston Rise in Rectory Farm - Johanna Bayes, of University Hospitals of Leicester, which ran the patient transport service, assured the coroner that steps were being taken to provide equipment and training for volunteer drivers.
Mrs Bayes said: “We have now provided equipment and protective clothing to volunteer drivers, as well as better training.”
However, the volunteer driver, Ronald Williams, gave evidence that he had not been offered any form of further training since the incident over a year ago.
Senior coroner for Northamptonshire, Anne Pember, agreed that the promise of training “clearly hadn’t happened” and said she would be looking into the matter further.
She recorded a narrative verdict and concluded that Mr Rokeby died from a complication with his dialysis fistula.
Mr Rokeby had been living with his parents since he found out in 2012 he had chronic kidney problems which would need dialysis.
On his last dialysis appointment before his death, he complained of pain and swelling in his left arm where the enhanced blood vessel - known as a fistula - was placed.
Renal specialists told him that the fistula had become infected and prescribed him antibiotics, but they sent him home until his next scheduled appointment.
Over the following two days, he phoned the Leicester hospital with concerns about it still being painful and tender, but was given little advice.
On the morning of his death on December 22 2013, Mr Rokeby was picked up by Mr Williams for his scheduled dialysis appointment.
In his statement during yesterday’s inquest Mr Williams said: “Mr Rokeby was usually chatty during our drives and we got on well, but this time he sat in the back of the car and didn’t seem to want to talk.
“About five minutes into the journey he said, ‘oh no, I’m bleeding,’ but said he could hold on until the next garage.
“When we arrived, I went in to get some paper towels and told the cashier to call an ambulance to tell them that the patient was bleeding seriously and that I believed he was going to die.”
Paramedics and police arrived soon after but pronounced Mr Rokeby dead at the scene at 8.25am.
Mr Rokeby’s father, Hedley Campbell, said: “I want to express my thanks to Mr Williams for the service he gave my family and for looking after my son, even though he wasn’t trained to deal with that situation and must have been very traumatised by it himself. I will never forget it.”
Mr Campbell went to the hospital to meet his son on December 22 shortly after he left with Mr Williams, but after some time waiting he was told by staff what had happened.
He said: “I hope lessons have been learned from this about giving proper training and equipment to volunteer ambulance drivers, as that might have made a difference.”
Matron Suzanne Glover, who tried to respond to a call from Mr Rokeby on December 19 for advice about the problem, said there had only been two deaths recorded in the last 10 years from dialysis fistula complications.