A 21-year-old university student tragically passed away just hours after being discharged from a medical clinic with only a steroid nasal spray, prompting a coroner to voice serious concerns about the care he received. Cian Everett, a student at Reading University, died on January 14, 2025, after developing a rare complication of sinusitis described as a "one in 100,000" occurrence.
Coroner's Findings and Neglect Ruling
Coroner Sarah Whitby, presiding over the inquest into Cian's death, stated that while she could not officially rule that neglect contributed to his demise, she harboured significant concerns about the medical treatment he received. "Just because I have not found neglect, it does not mean that I do not have concerns. The central issue seems to me is whether there were missed opportunities that could have saved Cian’s life," she remarked.
Mrs Whitby announced she would be issuing a "prevention of deaths" report to PHL Group, the organisation responsible for the Urgent Treatment Centre (UTC) at Lymington New Forest Hospital in Hampshire, where Cian was treated. A post-mortem examination revealed that Cian had a 6x4cm abscess on his brain and meningitis.
Missed Opportunities for Diagnosis
The treatment Cian required would have involved intravenous antibiotics and surgery to drain the abscess, which neuropathologist Mark Walker estimated had been developing for approximately five days. Despite two calls to NHS 111, two visits to the UTC, and one to a pharmacist, Cian was never referred to an Accident and Emergency department where the abscess would likely have been identified. Instead, he was diagnosed with sinusitis and given over-the-counter medication along with a steroid nasal spray.
The coroner expressed concern that a triage nurse and a doctor who saw Cian at Lymington hospital’s UTC the day before his death had not reviewed the notes from a 111 call he had made just an hour prior to his arrival. In those notes, Cian described a constant headache that felt like being "hit with a brick," along with vomiting, blurred vision, and lethargy. The presence of a "thunderclap" headache should have prompted a referral to A&E for scans, the inquest heard.
Systemic Failures at the Urgent Treatment Centre
Lymington hospital lacks the appropriate equipment to handle thunderclap headache cases and does not accept such patients. However, the 111 call handler failed to recognise this and directed Cian to the UTC. Upon arrival, Cian was registered as a walk-in patient. The coroner noted that a triage nurse should have realised from a message sent by 111 that the service had referred him.
Notes from the 111 call made on January 13, as well as from a previous call the day before, were transmitted to the UTC. The nurse did not read them, but Simon Corrall, lead clinical manager for the UTC, testified that he would not have expected her to due to the department's high patient volume. He stated that the UTC was "commissioned" for 60 patients per day but regularly saw up to 140. On the day Cian attended, there were 100 patients. However, Mr Corrall said he would have "absolutely expected" the clinician who saw Cian to have read the notes, adding: "If it had been myself, those notes would have triggered further questions."
Mr Corrall noted that 111 notes could often be "very long" and reading them might delay patient care. But the coroner countered that in Cian’s case, the notes were only about 15 lines, stating: "It’s not a big demand."
Doctor's Reliance on Face-to-Face Consultation
The coroner reported that Dr Simon Escalona "relied on the face-to-face consultation" and notes from a visit Cian had made to the UTC on January 3, when he was first diagnosed with sinusitis. Dr Escalona, who did not recall seeing Cian, wrote in his notes that Cian was "alert," "chatted," and described his headache as "on and off." Giving evidence, Dr Escalona admitted he was "unaware" of the 111 notes but stated that if he had read them, he would have questioned Cian further and would have spoken to Cian’s mother, who was in the waiting room.
Mrs Everett testified that her son was asleep on her shoulder, wearing a coat and under a blanket when the doctor came to get him. She remarked: "I don’t know how more drowsy you need to be." Despite these signs, Cian was sent home after Dr Escalona concluded that he was "getting better" and that antibiotics "were not needed."
Final Hours and Family's Grief
That evening, Cian vomited before going to bed. At 5:40 AM the next morning, his mother heard a "horrible gurgling" noise. When she rushed into his bedroom, he was not breathing. Mrs Everett performed CPR until paramedics took over, spending an hour trying to resuscitate him, but it was too late.
An investigation into Cian’s treatment at the UTC was conducted by Mr Corrall on behalf of PHL Group after his death. However, the coroner expressed that she felt "bothered" by the fact that the failure to read the 111 notes "doesn’t seem to have been recognised as a problem."
During the inquest, Dr Adam Ross, medical director of PHL Group, sent an email to the coroner acknowledging that the company’s report "did not place sufficient emphasis on the 111 call." The email stated that if Dr Escalona had read the 111 notes, it "may" have resulted in "further probing." It also accepted that the 111 information "should have formed part of the consultation" on January 13.
Prevention of Future Deaths
Mrs Whitby announced she would issue a 'prevention of death' report to PHL Group to determine "what they are going to do about ensuring their clinical staff" at all its UTCs read 111 referral notes. Recording a narrative verdict, the coroner stated that Cian died as a result of suffering an "extremely rare" complication of sinusitis. She noted that in the 24 hours before his death from natural causes, he had experienced a "rapid decline."
The coroner paid tribute to Cian’s family, particularly his paramedic sister Laura, whose input she found of "great assistance." Following Cian’s death, his family established the Cian Everett Young Person’s Development Foundation, which has already raised over £35,000. For more information, visit cianeverettfoundation.com.
