Jack Robert Bannister, aged 26, was described by his family as a popular and social man who was adored by all who met him.
Jack, who worked as a customer services assistant in Sainsbury’s, was born with Pierre Robin syndrome and spondyloepiphyseal dysplasia congenital (SEDC), the same bone growth condition as award-winning actor, Warwick Davis.
The inquest heard that Jack, who was from Leigh, was a keen gardener who enjoyed holidaying abroad with his family and friends, expressed a strong interest in property valuations and loved spending time with his beloved pet dog, Lottie.
Family, friends and close loved ones gathered at Bolton Coroners Court dressed in bright orange clothing, Jack’s favourite colour.
The hearing heard that on the evening of 17th December 2024, Jack began to experience abdominal pains in his stomach.
Despite calling 111 for an ambulance, Jack’s family noted that there were ‘severe delays’ of up to almost two hours in him getting seen to and so decided to drive him directly to Royal Bolton Hospital.
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Speaking at the hearing, Jack’s mum Gillian Bannister said: “At first, we thought Jack was suffering from constipation, although this wasn’t something he’d had issues with before.
“We were told by the nurse on the phone that the hospital would be notified of his condition and would be expecting him, but when we got there this was not the case.
“But Jack’s condition began to deteriorate even further once he arrived to Royal Bolton, he was screaming out in pain. He has a high pain threshold because of his SEDC, so we knew that if he was shouting like this it must have been excruciating.
“Anyone who would pass he would shout to them; he was desperate for help. He began to say that he was struggling to breathe. He wasn’t seen by the first triage for around 45 minutes, we were just told to wait for someone to be available.
“After he was eventually seen to by the first triage, I asked if there was a bed that he could use to stretch out, as he had just been cramped up in his wheelchair. It was only after I suggested he stretch out on the floor that they were able to provide us with a bed for him.
The inquest heard that there were delays for getting in contact with the surgical registrar, with senior doctors unable to contact them via the hospital’s switchboard.
Jack’s condition continued to worsen, the inquest heard that he was left ‘crawling on all fours’ due to pain following a CT scan whilst waiting for a surgical review.
Gill added: “When the residential surgeon finally came in, we heard her ask the clinical physician ‘why she had been called out for this’.
“We heard doctors arguing behind the curtain between themselves about where Jack should be best placed, he received atrocious care that evening.”
Doctors administered Jack with ketamine as a form of pain relief.
Gillian said: “He began spasming after the ketamine was administered, he had total fear in his eyes. I’ll never forget that look he gave me, this was the last time that he was ever conscious.
“I believe that there were significant delays at Royal Bolton that contributed to Jack’s passing. I just want to know if he looked like the average person would this have happened.
“There was a series of significant mistakes, concerns about Jack’s breathing were lot listen to, we tried to flag that his skin was mottling and didn’t get a response from staff. We felt like we were invisible, there was very little communication about what was happening.
“At one point we were asked to describe what his quality of life was like to the surgical registrar; I mean what kind of question is that?”
Although multiple members of staff attempted to insert a life-saving nasogastric tube into Jack’s nose on several occasions, the inquest heard that attempts were unsuccessful.
A needle decompression was considered by staff but deemed too high-risk and likely to result in gastric perforation.
Despite resuscitation attempts by doctors, Jack died after suffering from a cardiac arrest at 6.38am on 18th December.
A post-mortem examination found that his lungs had partially collapsed, and his stomach was ‘significantly dilated and full of air’ at the time of his death.
Speaking at the inquest, Dr Emma Wheatley, who compiled the NHS report following Jack’s death which described his death as ‘unavoidable’ due to the surrounding circumstances and that the ‘outcome would be the same.’
She said: “The nasal gastric tube would have been the life-saving procedure. But this wouldn’t go through, despite multiple attempts from senior people.
“Staff were unable to relieve pressure on his stomach, which pushed on the diaphragm and made it difficult for him to breathe. The team were unable to balance the pressure between his lungs and the stomach.
“His triage took about 90 minutes that night, I’m not saying it is acceptable by any means, but unfortunately that is the standard.
“There was a lot of stress between the teams that night, it is not a place for clinical teams to discuss plans in front of patients. Training is now in place to make sure people are being civil to one another and making sure there’s no blame amongst staff members.
“The quality-of-life question was insensitive, as this is difficult to determine. We are going to run a communications workshop about that so staff know how to get the best information out of people sensitively.
“Because we couldn’t treat the primary problem, it just added to more and more problems, which started with the inability to get the tube in.”
Gill added: “Jack lived life to the fullest, he had so much to live for and managed to cram so much into his cruelly cut short life.
“Everyone knew him and loved him, over 400 people attended his funeral including the staff at Sainsburys. He was popular, everyone would always compliment him on his beaming smile.
“Jack was the type of person who wanted to help everyone, he sat with his best friend, Jade, for 24 hours whilst she gave birth to his god daughter, Ophelia.
“He loved cars, a good gossip and designer clothes. He was so highly thought of and respected by so many people. He was my son, my best friend.
“Jack’s death was undignified, and we still don’t understand the reason for these delays on that night. There was so much that we believe could have prevented this and we felt like the communication wasn’t there.
“We just exist now, we don’t live. I believe he was let down by everyone there that night. I believe that they just looked at him, scratched their heads and didn’t know what to do.
“He was the same as everyone else, he worked in Sainsburys and was adored by his customers, he could drive and had so many friends and family who cared deeply for him.
“SEDC is not a life-limiting syndrome, I believe that they were well out of their comfort zone in treating someone of a different size and shape.
“He should still be here.”
A fundraiser for Jack’s family has raised over £2,000 of its initial £500 target.
Concluding, Coroner Ceri Owen said: “There was a failure to offer collation at the end of Jacks’ life, I don’t know why that was.
“I appreciate those in the medical field have competing demands, steps were taken to deliver care by staff of all seniorities.
“It is impossible to say whether sooner intervention would have had a different outcome. I did feel that some of his treatment was sub-optimal, but I’m not satisfied that the cause of death is neglect in this case.
“I agree with the post-mortem on the cause of death being metabolic acidosis, small bowel obstruction and spondyloepiphyseal dysplasia congenital.
“He was waiting from 90-100 minutes that night, with 95 other patients in A&E. There were delays in him getting a surgical review because of the descended stomach.
“The increasing intrabdominal pressure meant that he had difficulty breathing and unfortunately suffered a cardiac arrest which required advanced care support.
“Ultimately, I rule the cause of death to be natural causes. I offer my sincerest condolences to Jack’s family and friends.”
