‘Missed Opportunities’ Contributed To Nottingham Student’s Death, Inquest Finds

  • Amari Kennerdale, 21, died at home in Clifton in May 2020
  • A post-mortem examination showed Amari died from a pulmonary embolism caused by a large blood clot in his lungs, with the blockage stopping his heart
  • Inquest into Amari’s death found that there were ‘missed opportunities’ to assess him face to face on multiple occasions that could have led to further assessment in hospital and then life-saving treatment

On Friday, 17th September, Nottingham Coroner’s Court found that a series of missed opportunities contributed to the death of a 21-year-old student, caused by a pulmonary embolism just hours after being seen by his GP, an inquest heard.

Amari Kennerdale, of Clifton, was studying for a law degree at Birmingham City University but living at home with his family due to the Covid-19 pandemic. In April 2020, he began to complain about suffering from shortness of breath, chest pains and heart palpitations.

On 2nd May, Amari’s mother, Wendy, phoned 111 and was advised that someone would telephone back with advice. Instead, an ambulance was later dispatched and arrived at the property, during which time various tests were undertaken and Amari was diagnosed with a muscle sprain.

The next day, Wendy phoned 111 again as Amari’s symptoms continued but declined an ambulance, as they’d been upset by the paramedics’ attitude 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-19. 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, she wrongly selected the District Nursing Service, which had no electronic referral mechanism, and as a result, the call was incorrectly closed with no further action taken.

On 4th May, Amari phoned his GP practice for another assessment, after which he was referred for an urgent x-ray – this came back normal on 5th May. Five days later, Amari fainted in the middle of the night after waking up feeling unwell and vomited the next morning, which contained blood.

This prompted Wendy to phone the GP practice again on 11th May for Amari to speak to the nurse. After explaining that he was feeling very unwell, short of breath, with a history of chest pain, and a near-fainting episode, as well as his fingernails, being blue in colour, the nurse referred Amari to GP Dr Yap, who assessed Amari in the surgery car park that morning at around 11am. Dr Yap considered that Amari’s oxygen saturations were slightly low and advised him to buy an oxygen saturation machine.

That evening, Amari’s health took a dramatic downturn and an ambulance was called. Before they arrived Amari had stopped breathing and, despite CPR being performed by the family and treatment provided by the paramedics, Amari passed away in the evening of 11th May 2020.

At a two-day inquest into Amari’s death, which concluded on 17th August at Nottingham Coroner’s Court, the Coroner, Dr Elizabeth Didcock, found that if the findings from several healthcare professionals had been put together, it’s likely they would have led to concern about a pulmonary embolism, which necessitated hospital assessment.

The coroner also accepted the evidence of a leading expert in the field that, if Amari had been diagnosed correctly, he would have received treatment and would have had a good prognosis.

Speaking on behalf of the family, Wendy Kennerdale, Amari’s mother, said:

“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.

“We believe that this lack of communication between healthcare professionals, combined with the mistake made by the 111 clinical advisor after they assessed Amari and decided he needed to go to A&E, show the services failed Amari at the time he needed them most. He’d been crying out for help for two weeks.

“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.”

Emily Rose, Associate and Solicitor from our Medical Negligence team, has assisted Wendy and Amari’s family in preparation for the inquest. Barrister Ross Beaton of 7 Bedford Row has been representing him during the two-day hearing.

Emily said:

“It’s positive to see that the coroner identified several missed opportunities to assess Amari face to face, which could have led to hospital assessment. While this doesn’t bring Amari back, I hope that this will help to provide some answers to his family and we will continue to support them moving forwards.”