An inquest heard doctors took ‘no ownership’ of James Poot’s case in the months leading up to his death

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The chances of a popular young construction worker surviving a rare heart condition were reduced by failings in his care, a coroner has said.

James Poots was just 24 when he began complaining of chest pains in 2023. Later that year he was diagnosed with pericarditis, an inflammation of the lining around the heart.

Last week, a two-day inquest Rochdale Coroners’ Court heard heard how the Heywood resident’s condition worsened over the next two years, despite several hospital admissions. He tragically passed away at Wythenshawe Hospital in April 2025.

Nicholas Palmer, senior consultant cardiologist at the Liverpool Heart and Chest Hospital, reviewed James’ files and explained to the court how pericarditis ‘thickens’ the lining of the heart so it struggles to fully contract – but that ‘the vast majority of the time’ it resolves itself.

A tradesman who worked as a dryliner, James had been fit and healthy before falling ill, regularly attending the gym and playing five-a-side. But the court heard how he died aged just 26, following months of delays in sending him into theatre.

“By October 2023, there was evidence that this had been going on for a while,” Nicholas Palmer told Rochdale Coroner’s Court on Friday (February 6). “Progression is very unusual for someone so young. The initial treatment approach was conservative, opting for medication rather than surgery.”

But a heart scan in November showed ‘thickening’ fluid around James’ heart. “It looked as though it was progressing, not improving.”

An MRI scan was ‘recommended’ by James’ cardiologist Dr Jonathan Swan that month but not requested until December, by which time he had been diagnosed with constricted pericarditis, a more serious condition. The court heard that James did not undergo the scan until he was again hospitalised in May 2024.

“There was an excessive delay in this case,” said Dr Palmer. “There was clear cause for concern but no follow-up arrangements made. It was marked as urgent, but was not performed urgently.”

In May, doctors arranged a multi-disciplinary team meeting (MDT) at Royal Oldham, where Dr Swan pushed for a surgical referral, but Wythenshawe Hospital surgeon Dr Venkat declined this. The court later heard that he and the surgeon who eventually operated on James have since moved to the USA.

A further meeting was arranged for July 12, but James’ case was ‘not on the list’, the court heard.

“It should have been rolled over to the next meeting, but it was not,” Area Coroner for Manchester North Catherine McKenna said later.

“His case was then lost in the MDT pathway.”

Dr Palmer described this as the ‘crux’ of the problem. “There was a real need to discuss this case,” he said. “It seems there was no ownership of the patient, or making sure that there was close follow-up.

“There were ominous signs by July 2024 – massive alarm bells. How come by May the MRI had never happened?” he asked. “Urgency means that when requesting tests, I’m not just filling in a form and putting a patient in a queue, I’m making phone calls and saying ‘can I get this signed off.”

Dr Palmer said he believed that surgery ‘should have taken place’ in summer 2024. But James didn’t receive any further treatment until he was admitted to North Manchester General in the new year.

Two chasing letters had been sent by his GP in that time. By January, James was ‘extremely unwell’ with ‘significant evidence’ of heart failure. He spent 11 weeks in hospital, undergoing tests and being prepared for surgery. He was transferred to Wythenshawe for the operation in March.

The inquest heard later that the surgeon ‘had not realised’ how ill James was until he began operating and ‘saw the damage to his heart muscle’. He tragically died a week later, of multiple organ failure brought on by cardiac failure, itself brought on by constrictive pericarditis.

“The longer you leave a condition like this, the more the heart is affected,” Dr Palmer explained. “Six or seven months beforehand, it would have been less advanced, and would have given a better chance of survival.”

In her conclusion, Ms McKenna broadly agreed with this view.

“The MDT process at Royal Oldham Hospital failed,” she said. “By July 2024 he should have been referred for a surgical opinion as the medical route was clearly not working.

“All evidence indicates that James’ chances were reduced by the delays in his case. The progress of his condition and subsequent damage meant his ability to withstand surgery was reduced.

“He should have been treated with greater urgency. James was not given the opportunity for surgery that he should have been, when his chances of survival were better. That must make his death all the more difficult to bear for his family.”

Ms McKenna recorded James’ death as the result of natural causes, as pericarditis ‘is a rare but naturally occurring condition’, she said.

She also said she would not be issuing recommendations for the Northern Care Alliance, responsible for both Royal Oldham and North Manchester General hospitals, nor would she be issuing a prevention of future deaths report.

“NCA cardiologist Dr Timothy Gray said the MDT meetings process has been strengthened,” she said. “I heard evidence about how how doctors differentiate between and prioritise patients, and that there is a need for clinical ownership.

“That is what failed, and what was missing in this case,” she concluded.

When contacted for comment, Dr Rafik Bedair, Chief Medical Officer at the NCA said: “We offer our deepest condolences to James’ family at this incredibly sad and difficult time. Our thoughts are with them as they continue to cope with their loss.

“Our investigation found that the care James received did not meet the standard he and his family should have expected, and we are truly sorry.

“Reducing waiting times and minimising any risk to our patients is our highest priority. We continue to take steps to improve the way we work and ensure that cases with urgent clinical needs move forward without delay.”

MEN – Oldham