EXCLUSIVE: Man died from rare bleed on brain after medics repeatedly misdiagnosed it as sinusitis and failed to refer him for emergency CT scan

A DEVOTED father and husband died from a rare bleed on the brain after medics repeatedly misdiagnosed it as sinusitis and failed to refer him for an emergency CT scan.

Shre Chatterjee, 44, developed a "sudden and severe headache" on August 14 2023 but it was initially misdiagnosed as sinus and neck problems.

A senior coroner has said his life could have been saved had medics escalated tests and treatments much sooner.

An inquest, led by Rosamund Rhodes-Kemp, HM Area Coroner for the coroner area of Hampshire, Portsmouth and Southampton, heard he sought diagnosis and treatment on multiple occasions, but was never referred to A&E as an emergency until he became breathless, fell asleep, vomited and became unresponsive at home nearly two months later after a catalogue of blunders.

She has now called for urgent action in a Prevention of Future Deaths notice, including ensuring out of hours 111 doctors are able to book GP appointments for patients showing worsening symptoms.

It comes after Mr Chatterjee, who was a Consultant Engineer at Roke Manor Research, in Hampshire, also struggled to get a further appointment with his local doctor who may have made the much needed referral, the coroner said.

She wrote: "In mid- August 2023 (Mr) Chatterjee suffered a subdural haemorrhage, a rare type of brain bleed for someone of his age.

"He and his wife attempted unsuccessfully to get treatment for this on many occasions over the next 8 weeks.

"He sadly died at University Hospital (Southampton) on 12th October 2023.

"When by 25th September Shre Chatterjee described worsening Red Flag symptoms such as visual disturbance there was a missed opportunity to refer him to A &E for a CT scan.

"Again, on the 1st of October when, in addition to his other symptoms, he reported memory loss there was a further missed opportunity to refer him to A &E for a CT Scan.

"There was a final window closed to him in the early hours of 10th October when the ambulance crew did not convey him to hospital.

"Had he been taken to hospital on 25th September or 1st October a CT scan would have been arranged, surgery performed and on balance it is likely he would have survived. The short time frame on 10th October may make this less likely."

The inquest heard that between August 16 and 23 he was seen by two doctors and an Advance Care Practitioner, who all concluded it was caused by sinusitis and tension, so he was told to relax and was prescribed medication, including Amitriptyline, a prescription tricyclic medicine used to treat depression, nerve pain, fibromyalgia, and prevent migraines.

He was also referred for physiotherapy and osteopathy for soft tissue massage and spinal mobilisation.

But, by September 25 he twice called local medical services complaining of blurred vision over the past two weeks, so bad he could no longer drive, and severe pain, and was just told to see his GP as soon as possible.

At his second physio session on September 28, a healthcare worker recorded he had "headache, memory loss, blurry vision and was sleeping much more than usual" but referred him for a clinical call back.

On October 1 an out of hours doctor suggested he needed a scan for "reassurance" but was unable to refer him and said it had to be done via local GP services.

But, a GP appointment he had on October 6 was rescheduled for October 10 after the doctor was ill.

But, in the early hours of the same day he became breathless and an ambulance was called.

Paramedics from South Central Ambulance Service arrived at just after 4am but left as he had a morning GP appointment.

This was done on the phone with his wife, as he was asleep, and he was referred to the neurology department of the local hospital for later that day.

But, a second ambulance was called after he deteriorated and vomited but they found him unresponsive and took him to hospital, CT imaging revealed an acute chronic subdural haematoma.

He died there from the condition on October 12.

Following the inquest, which concluded on September 29 2025, Ms Rhodes-Kemp has now sent the Prevention of Future Deaths Report to Partnering Health Limited, an independent healthcare provider that delivers primary, urgent, and elective care services and clinical assessment support to the NHS and private partners.

She wrote: "In my opinion there is a risk that future deaths could occur unless action is taken.

"During the course of the inquest it became clear that while out of hours 111 doctors should be able to access direct booking with a patient’s own GP in cases requiring a face to face assessment, this facility is being blocked by some GP surgeries.

"This means that if a patient requires an urgent assessment the out of hours doctor can only refer them to contact the GP surgery, or direct to an Urgent Care Centre, which is supposed to treat minor injuries and where they may still not be examined by a doctor, and blood tests imaging are not available.

"In the deceased’s case despite numerous attempts to access a GP appointment he did not actually see a doctor from August 23 until he was eventually admitted to hospital with a by then fatal brain bleed on October 10 2023.

"It was agreed by witnesses that if a doctor had seen the deceased face to face sooner, particularly one who knew him, then the seriousness of his condition would have been diagnosed more swiftly and he was likely to have survived."

Mr Chatterjee was a popular member of the Hampshire Puja & Cultural Association and was "passionate about AI and machine learning", according to his Linkedin profile.

An online tribute to him said he was a "cherished member and devoted supporter".

It said: "His untimely departure has left a void in our hearts, and we fondly remember him for his warm smile, compassionate nature, and unwavering dedication to the HPCA. He will be dearly missed, and his legacy of kindness and commitment will forever resonate within our community."

NHS England, Partnering Health Limited and South Central Ambulance Service have been contacted for comment.