A man who waited eight months for a diagnosis and medical treatment could have been saved after dying at Royal Blackburn Hospital, an inquest has heard.

The inquest heard "systematic and human errors" had seen Mohammed Shahid Shaikh's case not be prioritised, leading to delays in care which if avoided could have prevented his death.

The court also heard how "personal commitments" and issues due to the Covid-19 pandemic meant he missed a biopsy, sending his case back to the bottom of the pile.

Mr Shaikh, 37, of Bowness Close, Blackburn, died on Thursday, June 16 2022, after he was admitted to Royal Blackburn Hospital due to 'severe jaundice'.

The inquest, at Blackburn Town Hall, heard how in October 2021, Mr Shaikh visited his doctor at the William Hopwood surgery in William Hopwood Street, as he reported he felt unwell, was losing weight and had 'yellow skin and eyes'.

His GP of nearly 20 years, Dr Satish Nagpal, who was present at the inquest, referred him for treatment at Royal Preston Hospital as his condition was too severe to be diagnosed by the surgery.

The court heard how Dr Michael Finegan, gastroenterology consultant from Royal Preston Hospital, rejected Mr Shaikh's referral after he said he needed to be seen more urgently by a different specialist within two weeks.

He also said the referral needed more information for Mr Shaikh to get an accurate diagnosis, but could see him in February if someone was unable to see him within two weeks.

The referral then went to the endoscopy service at Royal Blackburn Hospital, but the case was sent to the bottom of the waiting list, due to systematic and human errors not flagging him as a priority. 

Mr Shaikh's mother and sisters expressed concern during the inquest that the GP did not call and enquire whether his referral had been accepted.

Dr Nagpal said he was not made aware the referral was rejected, and "could not chase something" he did not know about. 

An ultrasound scan on November 23 showed Mr Shaikh had abnormal nodules in his abdomen, and required further investigation to determine the cause of his problems. 

On January 10, 2022, three months on from his first GP visit, Mr Shaikh was still unable to book an appointment and was told hospital staff were 'looking into' his referral.

On January 27, whilst he was still waiting for a referral, he was diagnosed with clinical jaundice.

Jaundice is the yellowing of the skin, mucous membranes, and whites of the eyes. It is a symptom of an underlying condition or health concern that involves the liver.

It occurs when the liver cannot keep up with the demand to process waste in the blood or when the liver becomes damaged. 

Mr Shaikh received an appointment with a gastroenterologist for an endoscopy consultation on February 17.

On March 14, a liver and pancreatic biopsy was booked for him, but he was unable to attend due to 'personal commitments' and issues with Covid-19.

This cancellation meant he went back to the bottom of the waiting list at the hospital, as the biopsy was cancelled on a Sunday, when referral staff were not at work.

The court also heard Mr Shaikh waited even longer for another operation date due to the hospital's IT system choosing a doctor who was unable to do the procedure he needed, a systematic error.

Mr Shaikh was admitted into intensive care at Royal Blackburn Hospital on Friday, June 3, 2022.

Professor Damien Lynch, consultant physician and gastroenterologist for East Lancashire Hospitals NHS Trust, who also attended the inquest, told the court although he did not work on Mr Shaikh's case, there should have been more communication between his GP, Royal Preston Hospital, and Royal Blackburn Hospital.

He said: "I would have liked to see more communication from the GP to check whether their patient had been seen, especially as his jaundice was extreme for a man of 37 years of age.

"I believe we would not be sitting here today if he got the right referral that was suggested when he first went to his GP."

On June 16, 13 days after entering ICU, Mr Shaikh died from liver failure after doctors predicted he had the underlying disease autoimmune pancreatitis.

When he was admitted into intensive care, doctors told his family his condition had progressed to levels that were untreatable.

Jackie Stanworth, operational manager of endoscopy at ELHT, told the court that since Mr Shaikh's death, there is now a new referral system to ensure this miscommunication does not happen to patients in the future.

This includes a new team which works seven days a week to triage the assessments they are given.

Reaching a narrative conclusion for Mr Shaikh's death, Coroner Richard Taylor said: "It is important to say the treatment Mohammed needed was not given, and from Dr Lynch's recommendation, I am satisfied to say if he did receive that treatment he would have still been alive.

"Mohammed died at Royal Blackburn Hospital after not receiving the necessary treatment he needed for his disease from the referral from his doctor.

"I hope the changes made at the hospital give the family a small sense of closure. I am very sorry for your loss."