Bury St Edmunds: Coroner says West Suffolk Hospital needs to learn lessons following woman’s death
12:00 22 May 2014
A coroner has said lessons need to be learned by a hospital after the fractured pelvis which contributed to an elderly woman’s death was not diagnosed.
Yesterday, a full inquest with witnesses took place into the death of Else Harvey-Samuel, 89, who had been living at the Martins care home in Bury St Edmunds.
She suffered a fall at the home on February 14 last year and was admitted to West Suffolk Hospital the following day. She passed away there on February 24 after suffering considerable discomfort and pain.
Mrs Harvey-Samuel’s family had had concerns that an X-ray of the pelvis was requested by a clinician as part of further investigations, but not conducted, and this had not been communicated to them.
Concluding the inquest, Coroner Dr Peter Dean said Mrs Harvey-Samuel died from complications following a fall and fractured pelvis contributed to by significant pre-existing natural disease.
He said in terms of lessons to be learned he had three recommendations for West Suffolk Hospital:
•that doctors requesting radiographs or other imaging investigations include sufficient clinical information to explain why it is needed to avoid a request being rejected and also to inform the radiologist;
•in the event of further need for justification for an out-of-hours investigation discussion between a senior clinician and senior radiologist should take place and be documented;
• and in any post untoward incident investigation the system must be satisfactorily robust to establish fully what happened and to take statements from anybody involved near the time of the incident.
Dr Dean said: “None of these three points are intended in any way as criticism of individuals, but clearly a system needs to be in place to ensure patients who present with difficult problems, particularly where the diagnosis is not clear for a variety of reasons, do have the benefit of the best possible system for that patient.”
The inquest heard that had the fractured pelvis been diagnosed an operation would not have been offered anyway as it is not a weight-bearing joint. What diagnosis would have been able to do was allow clinicians to better manage Mrs Harvey-Samuel’s pain and general clinical care, Dr Dean said.
He added he did not think knowing the pelvis was fractured would have alerted the “very tragic” outcome.
An incident report was carried out by Dr James Barrett, consultant radiologist, on May 24, but Dr Dean said had he judged the incident to be “serious” and a serious incident review was then carried out it would have given further insights.
A spokesman for West Suffolk Hospital said: “We would like to take this opportunity to pass on our condolences to Mrs Harvey-Samuel’s family. We will act on the coroner’s recommendations when we receive them.”