John BERROW · Prevention of Future Deaths report

On 18/10/19 an investigation was opened into the death of
John BERROW

The investigation concluded at the end of the inquest on: 1/12/20

The conclusion of the inquest was recorded as: Natural Causes

The medical cause of death was:

1a) Subarachnoid haemorrhage

1b Ruptured berry cerebral aneurysm

On 11th October 2019 John Berrow attended the Specsavers Opticians in Newport because he was suffering from unequally sized pupils. John stated that his eyesight was altered and he complained of increased pressure or heaviness.

An examination was performed by ████████, the optometrist who noted the disparity in size. Mr Campbell considered whether John’s symptoms could be as a result of an aneurysm or increased intracranial pressure, but the tests he performed reassured him that John’s neurological function was intact.

████████ diagnosed a condition known as Adie’s pupil an unusual neurological disorder in which the ability of the pupil to constrict is impaired, usually in one eye. This is not an emergency and as a result John was referred on a routine basis to the eye hospital.

John left the opticians at about 13:00hrs

John then went to the Queen’s Hotel in Newport and collapsed at about 15.25pm, he was resuscitated and taken to hospital. On arrival at hospital all attempts were made to fully resuscitate John but sadly his condition was irretrievable and John died at 16:50 hours.

The cause of John’s death was confirmed as a ruptured Berry Aneurysm. The neurological symptoms including unequal pupil size that John exhibited at his assessment at Specsavers should have resulted in John being advised to attend hospital for assessment. Given the severity and nature of his collapse however, there is no evidence that John’s death would have been avoided.

████████ gave oral evidence at the inquest hearing. In evidence he admitted that he failed to consider unequal pupils alone as a sign of increased intracranial pressure due to a bleed or aneurysm and has rectified this in his current practice.

He also stated that there were no practical reference tools or clinical manuals available to him within Specsavers and was dependent upon referring to Google to assist him in his clinical decision making.

I was also informed that whilst ████████ shared his experience locally, that there is no mechanism for disseminating information relating to clinical incidents or to improve learning from similar events amongst practitioners at Specsavers.