Man, 32, died after cyst was 'missed' by doctors

A mother whose 32-year-old son died after doctors and paramedics failed to detect a cyst on his brain, said she hoped the healthcare system would "take lessons" from his death.

Adam Cornell from Peterborough died on 11 June 2023

Cambridgeshire and Peterborough coroner Elizabeth Grey said there were "missed opportunities" which would probably have prevented his death. Cornell's "red flag symptoms" should have prompted emergency treatment in the lead up to his death, when he was attended by two GPs and a paramedic.

Maria Cornell said her son was a "kind, compassionate and extraordinary person" and that "losing him in these circumstances has been devastating beyond words".

Cornell died at Peterborough City Hospital after being admitted on 7 June 2023, having been found unresponsive at home, the coroner said in a report after a hearing last month.

He was found to have a cyst near the base of his brain which had caused a build up of fluid, "considered to be unsurvivable", the report said.

He had no significant past medical history before this, it added.

On 4 June, he attended the Hertfordshire Urgent Care (HUC) out of hours service, having experienced a headache, dizziness and fainting and was offered a GP appointment later that day.

He was deemed not to be experiencing red flag symptoms – which can indicate a more serious condition – and directed to visit his own GP.

That GP ordered an urgent outpatient CT scan and blood tests on 6 June, the report said.

Neither doctor ordered a fundoscopy, an eye examination which could potentially have alerted doctors to Cornell's condition.

Cornell's family called 999 on 7 June, but paramedics determined that a GP plan was in place and no further treatment was needed.

Cornell and his family were "not asked to explain why they had followed the GP's safety netting advice to call 999 or why they considered [his] symptoms worsened since his GP appointment the previous day", the report said.

Another ambulance was called on 7 June when Cornell became unresponsive.

An East of England Ambulance spokesperson said the service had "carefully considered" the coroner's findings and "acknowledge the conclusions reached".

"Patient safety is our highest priority and we remain committed to learning from incidents and inquests so that we can continually improve the care we provide," the spokesperson said.

HUC was contacted for comment.

In a statement provided by the Cornell family's solicitors, his mother said her son was "devoted to his family and friends".

"What happened to Adam should never have happened," she said.

"I hope the health professionals involved, and the wider healthcare system, take lessons from Adam's death," she said.

"Families should be listened to, warning signs must not be missed, and no other family should have to endure the pain and loss that we live with every day."

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