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Student who died from undiagnosed medical issue spent days trying to get help

A fit and healthy student who died from an undiagnosed medical condition spent days in pain and trying to get help.

21-year-old Amari Kellan Hamilton Kennerdale passed away at home from a massive blood clot which had moved to his lung.

An inquest in Nottingham heard how large blood clots dislodged from a thrombosis in his right leg vein, reports Birmingham Live.

On May 11, 2020, the significance of his medical history and 94 per cent low oxygen saturation were not linked together as consistent with pulmonary embolism, said the coroner, which would have required a hospital assessment and treatment.

Speaking on behalf of his family, Wendy Kennerdale, Amari’s mother, said: “Amari was an incredibly kind and caring young man who was loved by all who knew him and it was absolutely devastating to watch him not get the help he so desperately needed.

“He was a very fit and healthy young man who regularly attended the gym and there was no doubting that he had a bright future ahead of him. He touched the lives of everyone he crossed paths with, so much so that his cousin, Liam, and friend, Brynn, have taken over the gym he used to go to and named it ‘Amari’s Universe’ – making sure that his legacy and memory will live on for decades to come.”

His father, Karl Hamilton, 52, of St Ann’s, who attended the inquest, said his son was studying law at Birmingham City University.

He spoke of how his son tried to get help for nine days and ended up dead.

Medical professionals had tried to find out was what happening with his son ‘for all them days’, he added.

He added: “Amari was pure joy. We laugh from when he was a baby. We always laugh together. He was kind and thoughtful of others. He was also a sportsman, a footballer,” Mr Hamilton said.

Mr Kennerdale was seen by paramedics in May 2, 2020, in the first few months of the pandemic, and his medical observations had been okay but his mother had said his pain continued.

Mr Kennerdale was seen by paramedics in May 2, 2020, in the first few months of the pandemic, and his medical observations had been okay but his mother had said his pain continued

They called 111 again the next day as his symptoms continued but declined an ambulance as the inquest heard they had been unhappy ambulance staff had been “dismissive” off their concerns the previous day.

A call back was received on this occasion from a clinical advisor. Her assessment was that he should attend A&E and that would have been her recommendation if it weren’t for Covid. However, due to her concerns about the pandemic, she explained that instead of sending him to A&E, she was going to arrange for him to have a call back from an out of hours doctor within an hour.

However, no call back was made.

On May 4, he phoned his GP practice for another assessment, after which he was referred for an urgent X-ray – this came back normal on May 5.

But then he nearly fainted, his heart was racing and he had vomited with a small streak of blood in it.

Mr Kennerdale had spoken to a nurse practitioner at his family surgery, John Ryle Medical Practice, Clifton, and described pain in his left shoulder and left side which worried him as he was finding it difficult to breath.

He had said the pain had now gone but his breathing was no better and the vomit had contained two small blood clots.

It was decided he should go to the surgery on May 11, 2020. At the time, patients were being seen where necessary following telephone consultation and triage by its clinicians.

As much as possible, patients were being assessed in their cars, which was described as being in accordance with the guidance at that time and a primary care decision, not one of the practice.

Mr Kennerdale was driven in an SUV to the surgery by his cousin and seen in the car park of the practice by Dr Sue Yap, who had been briefed by the ‘extra thorough’ practice nurse earlier.

She was asked by assistant coroner Dr Elizabeth Didcock, who gave a narrative conclusion, if she had reviewed the content of 111 reports before she saw him.

Dr Yap said she had not looked at them.

She told the hearing on Friday, September 17: “I had 17 patients booked in. Amari was an extra”.

She said a patient coming in the car would be asked to draw up to an emergency exit of the surgery and park right in front of the fire exit, then she asked them to call the surgery and she would get a message they had arrived and collected her medical equipment.

Mr Kennerdale had told the doctor he was feeling better and did not have pain anymore. However, he did not feel his fitness level was the same. He felt tired, short of breath on exersion, for example, running up the stairs.

She said he did not look unwell and he was speaking in full sentences. She checked his blood pressure and listened to his chest and he was ‘breathing very gently and normally’.

His oxygen saturation was ‘sitting on the fence’ – was the word she used to Mr Kennerdale and his cousin.

She did not say ‘you have Covid-19’ because at that point there was no community testing, the inquest heard.

She said he was a gentleman who was fit and well, who looked after his health, and had not had surgery until 2015 to his knee.

She had spoken to him about coming back if things got worse or to give the surgery a call and debated it would be faster, if he felt unwell, for a family member to drive him to hospital.

A consultant from the Royal Brompton Hospital, London, was asked to be an expert witness in the case and he said, after hearing the doctor’s evidence: “For her, I can completely see why for her Covid was the likely diagnosis”.

Delivering a narrative verdict, Dr Elizabeth Didcock said there had been missed opportunities to assess him.

Amari’s mother added: “It was abundantly clear to us that Amari was presenting very serious symptoms of breathlessness, chest pain and palpitations.

“However, we feel that the people who assessed him prevented him from going to hospital and receiving the treatment he so needed due to a combination of miscommunication and errors – based on the isolated contact they had with Amari, rather than based on the progression of his symptoms that we saw as a family.”

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