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Royal Cornwall Hospital Trust (RCHT) has apologised for causing additional stress to the family of a exhausted hospital worker who died after crashing his car and wandering into a freezing river.
Lab scientist at the Royal Cornwall Hospital, Adam Spoors, died after walking in a "state of exhaustion-induced delirium" and falling into the River Kenwyn, as he felt under pressure at work following a promotion.
An inquest into the 39-year-old's death was held on Wednesday and Thursday, November 19 and 20, but was not attended by his colleagues. RCHT has said that Adam's colleagues were unable to attend the inquest in person due to the short notice, despite the Coroner offering three dates for the hearing.
In a statement, RCHT said members of staff who worked with Adam had "every intention" to attend the inquest in person, but they were unable to go as there was not enough time to cover the shifts of the workers who are integral to patient care. However, it said a representative for the RCHT did attend.
In a statement to CornwallLive, a spokesperson for Royal Cornwall NHS Trust said: "Adam's colleagues had every intention of attending his inquest in person.
"The Coroner offered three dates for the hearing and chose to go ahead with the only one we had said our staff were unable to attend, as it was too short notice to get cover for individuals who carry out work critical to the delivery of patient care.
"Our request to the Coroner for an adjournment was declined. A representative for RCHT did attend the inquest.
"We are deeply sorry this has caused Adam's family additional distress which we had tried hard to avoid."
CornwallLive reported that Adam was so exhausted and stressed from his work that he crashed his car on the road leading him home then walked in a straight line in a state of exhaustion-induced delirium, through thick brambles before falling into the cold water of the River Kenwyn.
The inquest into Adam's death heard how laboratory staff were required to work a 24/7 rota which included long 12-hour night shifts at weekends. It heard how staff were on their own during some shifts despite Royal Cornwall Hospitals Trust admitting the optimum number of staff needed for such shifts was two.
On the night of his death on March 29, the inquest heard that Adam had been working alone having already done a night shift the night before, as well as a late shift, an early shift and a day shift the same week. The inquest heard that Adam had felt under pressure to perform in his new senior role and had not felt able to refuse doing the second back-to-back night shift when asked to do so by his line manager.
Assistant coroner Guy Davies said: "Adam was engulfed by a perfect storm from work-related stresses and pressures that put him under psychological duress." The medical cause of his death was given as hypothermia from cold water immersion brought on by acute stress.
Mr Davies, who recorded a narrative conclusion, said there was no doubt Adam had been in a state of exhaustion and was "experiencing overwhelming psychological stress" which led to his "state of complete disorientation".
You can read the coverage of the inquest here.
Following the hearing Adam's widow Amy told CornwallLive: "I am grateful to Mr Davies for fully appreciating the depth of the stress that my husband faced at work, and by attributing his cause of death as acute work induced stress highlights what I perceive to be the failings of the hospital to show their staff any level of care or support.
"The fact that Mr Davies said he hasn't done this in his career as a coroner before is testament to extreme nature of Adam's death. The fact that four members of staff from RCHT were summoned as witnesses and did not attend highlights their utter lack of support to Adam even after his death.
"I cannot move on from the fact that Adam's death was wholly preventable, had he been shown an ounce of care from RCHT. If a colleague is so stressed that you have to go through a wellbeing toolkit in the middle of the night with them then perhaps they should have been sent home.
"Perhaps they should have been excused from line working the next night. Mine and my children's worlds have been destroyed, and RCHT do not seem to care in the slightest."