A football referee who caught a stomach bug on a Mediterranean holiday died a fortnight later after a Norfolk hospital blunder saw him treated with just half the recommended drugs dose.
Colin Greenway, 63, a prominent official in the local football community, was on a trip to Peyia, on Cyprus, with five other members of his family when some of them became unwell after drinking some of the local water.
He was still poorly when he got home to Swaffham and sought medical treatment.
He was admitted to the Queen Elizabeth Hospital in King's Lynn, where it was discovered he had caught an infectious disease called campylobacter.
The bug is associated with eating undercooked meat and seafood or drinking untreated water.
However, the junior doctor who treated Mr Greenway on the weekend he was admitted prescribed half the usual dosage of medication used to reduce the risk of developing blood clots.
After Mr Greenway's blood results improved, he was sent home but died in bed of a pulmonary embolism four days later.
Over the course of his hospital stay, his prescription was not checked by a senior clinician, consultant or pharmacist.
And it was only when wife Sue Greenway, a retired medical practitioner herself, questioned whether he had been correctly dosed that the mistake was discovered.
Mrs Greenway said: "It was an absolute shambles but my biggest concern around it is that had I not been a medical professional none of this would have come to light.
"My whole world ended when he died."
Following an inquest into his death, a coroner warned further people could die if the hospital did not improve its approaches.
In a report to prevent future deaths, area coroner Yvonne Blake wrote: "It is the consultant doctor's responsibility to check what their junior, unsupervised doctors do at the weekend when a patient is admitted.
"This consultant did not ever speak to this junior doctor about the misprescribing or know what action - if any - had been taken about it.
"I was informed by a senior nurse that other such drug errors have occurred since Mr Greenway died."
Ms Blake said she was concerned that Mr Greenway received "no continuity of care" after being seen by three separate consultants over three days.
She added: "While the consultants, three saw Mr Greenway, continue to refuse to accept responsibility for doctors prescribing, this situation continues."
In her report, Ms Blake highlighted a number of concerns about the care the football referee received.
This included:
• That the junior doctor had made an incorrect prescription, despite having clear guidelines
• That consultants had considered it the job of pharmacists to check for errors while only providing service three days a week
• That consultants were not "accepting responsibility" to monitor junior doctors' prescriptions
Govindan Raghuraman, acting medical director at the QEH, said: "On behalf of the Trust, I reiterate our sincere condolences to Mr Greenway's family.
"We have reviewed Mr Greenway's care in great detail and have carried out an internal investigation.
"The trust is developing an individualised action plan as a result of Mr Greenway's inquest.
"Specific actions are being developed to address the coroner's concerns.
"We will formally update the coroner on the progress as soon as actions are finalised, who will, in turn, update Mr Greenway's family."
Ms Blake concluded that while it is not possible to say if a full dose would have prevented his death, she still had serious concerns about the care he was given.
Mr Greenway leaves wife Sue, son Matthew, 26 and daughter Ellen, 33, who is due to give birth to his first granddaughter in just a few weeks.
All four of them were on the trip to Cyprus, along with Mrs Greenway's mother and aunt, who has a holiday villa on the island.
Mrs Greenway added: "It breaks my heart that he will never get to meet his granddaughter because he was failed so badly."
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