“The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections…”

The coroner’s concerns

(1) The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections between April 2021 and May 2022 was provided across three different health trusts and hospitals, Musgrove Park in Taunton, North Devon District Hospital in Barnstable and Exeter Hospital; it is acknowledged that this was as a consequence of Mr Tizard- Varcoe’s 1 vascular disease (being treated at Musgrove Park) and the locations of specialist doctors. Whilst being treated at Musgrove Park for a vascular problem, Mr Tizard-Varcoe consulted with ear nose and throat specialists for ear pain; subsequently between April 2021 and May 2022 he was seen on a number of occasions by clinicians in all three locations; this led to occasions when Mr Tizard -Varcoe was reviewed by clinicians without the full clinical picture due to the inability of separate hospital trusts to access each other’s medical records. The evidence revealed that on occasions it was difficult for Mr Tizard-Varcoe’s GP to work out who had responsibility for his care. It is my judgement that on occasions this led to less than optimal treatment for Mr Tizard Varcoe. (2) In addition, the evidence revealed that there were three occasions when Mr Tizard-Varcoe was not followed up as an outpatient in a timely manner (August 2021, November 2021 and February 2022). On one occasion Mr Tizard-Varcoe possibly ran out of antibiotic medication and on another Mr Tizard-Varcoe was discharged without antibiotic medication. The lack of timely follow up appointments resulted in reduced monitoring and assessment and a poor understanding of the effectiveness of treatment and the progression of his ear infection. (3) In addition, on the 1 November 2021, Mr Tizard-Varcoe was discharged from the Royal and Devon Hospital without a prescription for oral antibiotics despite advice from microbiologists to do so; the evidence showed that this was a clinical decision made by a junior ear nose and throat doctor against an improving clinical picture. The discharge was overseen by a consultant from a different specialism due to Mr TizardVarcoe’s health needs at the time. Evidence at the inquest from the responsible ear nose and throat consultant, indicated that he would probably have prescribed antibiotics on advice of microbiologists. Due to the progression of the infection from the ear canal into the bone at the base of the skull there is a real possibility that the clinical presentation did not reflect the true situation and this was a missed opportunity to provide continuity of treatment.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0321

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0