A father-of-three died from a burst blood vessel the day after being discharged from hospital with Gaviscon to treat heartburn, an inquest heard.
Daren Hooper, 42, was rushed to hospital after collapsing at work and was diagnosed with gastro-oesophageal reflux and given antacids as treatment.
But doctors failed to carry out a CT scan which would have spotted if a leaky artery was slowly filling his chest with blood, the hearing was told.
He collapsed at his home in Ruishton, Somerset, less than 24 hours after being discharged and died en route to Musgrove Park Hospital in Taunton.
Recording a narrative verdict, coroner Michael Rose said that “not enough consideration” was given to his diagnosis and that a CT scan could have saved his life.
The inquest in Taunton, Somerset, heard how Mr Hooper had suffered from gastro-intestinal problems for more than a decade.
Three days before he died the project manager collapsed at work and was rushed to the Bristol Royal Infirmary.
He was diagnosed with gastro-oesophageal reflux and – despite suffering from severe chest pains – was not given a CT scan that may have spotted any damage to his aorta.
Mr Hooper collapsed at home on January 16, 2012, where his young son Archie called an ambulance.
He went into cardiac arrest en route to hospital in Taunton and neither the paramedics nor the emergency resuscitation team at the hospital were able to revive him.
His wife Kath, who was with him in the ambulance, told the inquest: “I was leaning over Daren and his eyes went. They just went.”
A post mortem recorded his death to be haemorrhage caused by a ruptured aortic aneurysm – a massive amount of blood which filled his chest.
The aorta is the largest blood vessel in the body and a rupture is a catastrophic medical condition which carries just a three per cent survival rate.
The inquest heard evidence from five doctors who treated him at the Bristol Royal Infirmary.
Dr James Ritchie was a junior doctor at the time and flagged up the possibility Mr Hooper’s condition may have been more serious than originally thought.
He told the inquest: “I considered the possibility of aortic dissection.
“I asked the nurse to check Mr Hooper’s blood pressure in both arms and I checked that his right and left pulses were equal in volume and synchronous, which they were.”
He added: “I was aware that these were possible signs of aortic dissection but I was unsure how reassuring the normal findings were.”
Dr Ritchie and senior medic Dr Alasdair Macrae checked the chest x-ray, which showed no sign of aortic aneurysm or dissection – where part of the lining of the aorta breaks apart and splits inside the artery.
Mr Hooper, a project manager at a property firm, was given Gaviscon during his stay in hospital, the inquest heard.
Coroner Mr Rose said: “This is a tragic case. The deceased, Daren Mervyn Hooper, was 42 years of age and I would hope he would have a good life ahead of him.
“My assessment is I feel not enough consideration was given to what admittedly is a rare but not impossible consideration that something had gone wrong with the aorta.
“We do not think that full consideration was given to the actual matters that subsequently led to his death.
“When he was discharged from hospital, he was not the man his wife knew two days earlier.”
Ruptured aortic aneurysms in the chest affect only one in 100,000 patients, but the chances of suffering one are dramatically reduced with age.
Mr Hooper was in an age bracket where the NHS see perhaps only two or three cases a year, the inquest was told.
Mr Rose added: “Had the consideration that Mr Hooper was suffering from an aortic leak been fully considered, a CT scan would have been conducted.
“His leaking aortic aneurysm would have been discovered and this may have led to successful surgery.”
Speaking after the hearing, Mr Hooper’s wife Kath said: “I am satisfied that today’s inquest has acknowledged that there are some serious issues for the Trust to address following the death of my husband.
“Expert opinion states that his death could have been avoided if he had been given a CT scan when he visited Bristol Royal Infirmary.
“Indeed, the doctor dealing with him raised the possibility of such a scan but was informed by a senior that it wasn’t necessary – that fateful decision has completely devastated my family.
“It hasn’t been helped by the minimal psychological support offered for myself and my children.
“I will now campaign for better support for bereaved parents and children who really need it to help them rebuild their lives.”
Mr Hooper is survived by his wife Kath and their three children, Joseph, 15, Archie, nine and Darcy, four.
Kath’s solicitor Andrew Hannam commented after the case: “We will now consider our options in terms of pursuing this matter further with the objective of securing the kind of support the Hooper family deserve to help them cope without a husband and a father.
“Meanwhile, it is important to point out that this tragic event has been investigated thoroughly by the Trust who accepted that Darren Hooper’s death was regarded as a Serious Untoward Incident.
“The Serious Untoward Incident investigation has resulted in training for staff at Bristol Royal Infirmary to ensure this ‘knowledge gap’ is closed and these circumstances don’t occur again.”