21-year-old Cian Everett died in the morning of January 14, 2025, following a visit at the urgent treatment center (UTC). The young man experienced constant headache and described feeling as though he had been “hit with a brick” when he called 111 an hour before visiting the hospital.
Sadly, once at the hospital, the nurse and the doctor who assessed him didn’t read over the notes from his call and didn’t realize the severity of the situation so they didn’t refer him to A&E.
Instead of offering medical help, the young man was simply advised to use nasal spray and inhale steam from a bowl of hot water when he got home, according to the inquest revealed this week, The Sun reported.
It turned out that Cian developed a “one in 100,000” complication of sinusitis, which led to his death just 12 hours later.
Cian, who attended the University of Reading, had a 6x4cm brain abscess in his right temporal region, alongside severe swelling caused by acute meningitis, the autopsy revealed.
Following a two-day inquest at Winchester Coroner’s Court, the coroner, Sarah Whitby, raised alarms over potential “missed opportunities” that could have saved Cian’s life. Because of this, she’s issuing a formal ‘prevention of future deaths’ report to the PHL Group—the company running the urgent care center at Lymington New Forest Hospital where Cian was looked after.
Cian’s mom, Gillian, spoke of the night her son died and recalled telling him she oved him and leaving him a washing up bowl in case he continued vomiting. She also said that Cian had always been a healthy person and no one realized how ill he was and how severe his headache was.
The young man started experiencing headaches in December, 2024. He was taken to Lymington New Forest Hospital after being unable to secure a doctor’s appointment, as per the inquest, but he was only prescribed nasal spray for sinusitis.
However, as the excruciating headaches continued in the weeks to come, his mother got extremely worried. Cian was lethargic, freezing cold, and barely eating. On January 12, Gillian called 111 and was advised to take him to a pharmacy, where he was once again diagnosed with sinusitis. However, after he threw up during the night and couldn’t even manage to get out of bed the next morning, Gillian knew he was getting worse. She testified at the Winchester Coroner’s Court inquest that being that drowsy just wasn’t like him at all, as per The Sun.
“He was really lethargic, and I was really worried about him because this was so out of character,” his mom said.
Sinusitis commonly follows a cold or flu, causing facial pain, swelling, and green or yellow mucus. The NHS recommends an urgent GP appointment or calling 111 if symptoms worsen. When Gillian called 111 again, Cian reported vomiting, blurred vision, and a severe “thunderclap” headache.
The two then went to an Urgent Treatment Centre (UTC), where neither the triage nurse nor locum doctor Simon Escalon read the 111 call notes. Instead, Dr. Escalon reviewed older records and concluded Cian was improving because his nasal discharge had cleared. Finding his vitals normal and noting no confusion, the doctor skipped further testing, stating a brain abscess usually causes a drunk-like walk and drowsiness.
Cian’s mother, who was sitting with her family at the inquest, interrupted the doctor, telling him: “He died 12 hours later.”
At the inquest, Dr. Escalon insisted that had he known about the severe symptoms, he would have referred Cian to Southampton A&E for scans, as the local UTC lacked the proper equipment. The 111 handler failed to recognize this limitation when routing them, and the UTC manager noted the busy department meant nurses weren’t expected to read the 111 notes.
According to his mother, Cian said the doctor examined his sinuses and ruled out a bacterial infection because pressing on them did not cause discomfort.
That night, he struggled badly. He ate only a couple of mouthfuls of dinner and spent the evening wrapped in a heated blanket because he could not get warm. While watching Harry Potter with his mum, he took pain relief for his worsening headache.
After vomiting on the stairs, he went to rest.
Early the next morning, at around 5:40 a.m., Gillian heard a frightening gurgling noise coming from his room. She rushed to him, but despite shaking him and calling his name, he did not respond.
Realising he was no longer breathing, she phoned 999 and performed CPR until paramedics arrived quickly at the house. Sadly, they were unable to save him.
A pathologist later confirmed that Cian had developed a rare brain abscess caused by sinusitis, a complication considered extremely uncommon.
During the inquest, the coroner said she would contact PHL Group through a Prevention of Future Deaths report regarding procedures at urgent treatment centres and the handling of NHS 111 referral notes.
She concluded that Cian died from a natural but rare complication of sinusitis after his condition rapidly worsened within just 24 hours.
The coroner also thanked the family for their valuable contribution to the investigation.
Dr Andrew Ross, PHL Group Medical Director said: “We extend our sincere condolences to Cian Everett’s family.
“We note the Coroner’s findings and the Prevention of Future Deaths report.
“Patient safety remains our highest priority at PHL Group and we are carefully reviewing the concerns raised.
“Where improvements are identified, we will act swiftly to implement them and work with partners to reduce future risk.”
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