Isaac Arrowsmith was diagnosed with Haemoglobin Rainier disease, a rare inherited blood disorder that raises the risk of blood clots, at the age of 18.
On December 19, 2025, Isaac, 19, developed chest pain and breathlessness and started coughing up blood.
He was diagnosed with pneumonia at Macclesfield District General Hospital and was discharged with antibiotics.
No vital test was done to rule out a pulmonary embolism – when a blood clot blocks blood flow to part of the lungs. It can be life-threatening if not treated quickly.
On 31 December Isaac saw his GP who felt that a chest infection did not completely explain his symptoms, particularly given his medical condition, and referred him for additional tests.
Before these could be undertaken, Isaac returned to A&E that same day, coughing up a larger quantity of blood.
But he was told he would be put under a respiratory virtual ward – designed to deliver hospital-level care at home within 48 hours – rather than being admitted.
Later that evening, he returned to hospital coughing up more blood.
Mum Louise, a 52-year-old manager, said that after waiting around 20 hours without being seen, Isaac went home on January 1 believing he would be followed up through the virtual ward.
On January 2, however, he collapsed at home and died from a pulmonary embolus, deep vein thrombosis and Haemoglobin Rainier disease.
An inquest later found that his death was preventable, concluding he was never referred to the virtual ward team.
In her conclusion, coroner Victoria Davies said: “No referral was made to the virtual ward team that day and, had it been, it would not have been accepted, and Isaac would have been admitted to hospital.”
Writing in a Prevention of Future Deaths report, she also said: “Had Isaac been admitted to hospital on December 31, he would have been in hospital at the time of his deterioration on 2 January and would have been successfully resuscitated.
“The lack of referral to the virtual ward team and misunderstanding as to suitability for the team caused or contributed to Isaac’s death.
“There was a lack of weight given to Isaac’s underlying haematological condition and the linked risk of a clot and, as such, a lack of appropriate consideration of a blood clot.”
Recalling Isaac’s devastating ordeal, dad Neil, a 45-year-old tutor, said: “I think his death would have been easier to accept if there was nothing anyone could have done.
“Now it’s hard not to get angry – Isaac should still be here with us today, and he isn’t because of mistakes in his care.”
After Isaac’s diagnosis of Haemoglobin Rainier disease, he received treatment at The Christie NHS Foundation Trust, involving regular blood tests and venesection.
Mum Louise said that when Isaac first went to A&E via ambulance on December 19, and she told staff about his condition, she was “shocked” to discover not all A&E staff could access patient files.
“We put our trust in the doctors and thought the antibiotics needed to kick in,” dad Neil said.
He added that Isaac’s condition was “up and down” over Christmas, which the family spent together despite Neil and Louise being divorced.
On December 31, after attending A&E again at Macclesfield District General Hospital, he was again diagnosed with pneumonia, but a doctor ordered further respiratory investigations before he was told he would receive support from the respiratory virtual ward team within 48 hours.
On the morning of January 2, Isaac was still breathless but told Louise he “felt OK” before she went to work.
Later that day, he called her, struggling to breathe, and she sent Neil, who lived five minutes away, to check on him.
Neil said Isaac was “pale” and “confused” when he arrived, so he called 999 and tried to calm his son by encouraging him to take deep breaths.
“He suddenly lunged back and was gasping for air,” he said.
“I got him into the recovery position on the sofa and rang 999 again.
“He’s not breathing, and I’m in hysterics at that point, and they talked me through CPR over the phone.”
Paramedics tried to resuscitate Isaac but were unsuccessful, and he died at 3.57 pm.
Neil then called Louise, and they told Isaac’s younger siblings, Luke, now 18, and Naomi, now 15, that “their big brother isn’t coming back”.
The inquest at Cheshire Coroner’s Court concluded on May 20 after hearings beginning in January.
Louise and Neil expected to hear that “nothing more could have been done”, having already received a letter from East Cheshire NHS Trust after an internal investigation said as much.
However, after the inquest heard that the lack of referral to the respiratory virtual ward team caused or contributed to his death, Neil said: “It was a bombshell moment”.
He added: “It was as if they didn’t even really understand what a virtual ward was themselves… or how to follow their own process.”
“There were clear signs of pulmonary embolism, and they just disregarded it; it was horrendous.”
In the Prevention of Future Deaths report, the coroner also raised concerns that similar deaths could happen unless action is taken.
Neil and Louise said they did not receive a formal apology from the hospital or East Cheshire NHS Trust at the time.
Louise said: “They won’t take any accountability. I’d be concerned for anyone seen by the doctor who didn’t make the referral – in my opinion, they are not fit to practise.”
Louise and Neil have reported the case to the Care Quality Commission.
They have since got back together, and say they are taking life “day by day”.
Neil said: “We realised we needed each other. Louise is the only other person who knows what I’m going through and feeling, and vice versa.
“We’re also fundraising for the Scouts because Isaac went for years, and it made him the man he was.”
To date, their JustGiving page has raised more than £3,700.
Dr John Hunter, chief medical officer at East Cheshire NHS Trust, said: “We would like to offer our sincerest apologies to Isaac’s family and friends. He did not receive the high level of care he should have had from us, and for this we are truly sorry.
“Following the coroner’s review of the evidence, and the issuing of a Prevention of Future Deaths report after Isaac’s tragic death, we have considered the findings fully and undertaken a detailed review of the areas where we fell short in Isaac’s care.
“As a result, we’ve strengthened our educational programme within the trust to support clinicians in recognising how and why a misdiagnosis may happen.
“In addition to this, we’ve also increased clinical awareness of thrombotic risk factors and the importance of early recognition and escalation.
“We’ve also undertaken a review of our electronic patient record system, the findings from which will help support clinical decision-making in identifying and managing patients with an increased risk of venous thromboembolism.
“And we’ve also carried out a thorough review of how we conduct multidisciplinary reviews within the trust, and an action plan has been drawn up to address the issues identified by the coroner.”
A spokesperson from the Care Quality Commission said: “We are aware of this very sad case and have had contact from Isaac’s family. We offer them our condolences.
“We are following up with the trust to seek further information and are reviewing their response to the coroner’s Prevention of Future Deaths report to determine whether there’s a need for further action on our part.”
The family are receiving support from medical law specialists Enable Law regarding their legal options and any further investigations.
Mike Bird, a partner and their solicitor at Enable Law, said: “It’s agonising to read Isaac’s story.
“The coroner’s inquest was incredibly important, because without that, the family would have been misled into believing that Isaac’s death was an unavoidable tragedy.
“I desperately hope the changes the trust says it has implemented actually have a lasting impact on the NHS front line. We are in Isaac’s family’s corner.”
The phrase “NHS heroes” feels painfully hollow when preventable deaths like Isaac’s show a system so overstretched that heroism has become a substitute for basic safe care.
A young man died because errors kept stacking up, yet no one is held responsible for the failures that cost him his life, and the NHS feels beyond investigation, a system where failures pile up faster than anyone is ever held to account.
Outrage is everywhere — people saying the NHS has become a system where preventable deaths happen and nobody answers for them.
People are raging, saying sorry doesn’t fix a system where mistakes pile up, investigations go nowhere, and responsibility simply evaporates, and people are furious, saying it’s unbelievable that in 2026 the NHS still doesn’t have a central system where every hospital can access a patient’s full medical history, and that lives are being lost because basic information isn’t shared.
This has to stop NOW — people are dying while hospitals treat it like a box‑ticking exercise to “learn lessons”, shutting the barn door long after the horse has bolted.
THE MONTHLY MOSQUITO 