Partly Cloudy

Partly Cloudy

max temp: 21°C

min temp: 17°C

ESTD 1874 Search

The pigs have arrived. See the latest

Pigs Gone Wild

news here.

Bury St Edmunds: Coroner says West Suffolk Hospital needs to learn lessons following woman’s death

12:00 22 May 2014

Coroner Dr Peter Dean

Coroner Dr Peter Dean

Archant

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.”

1 comment

  • Good luck to Mr Gearing and his ilk who campaign for sensible speed limits and thankyou to EADT for reporting them. Sadly, in Suffolk, these campaigners are knocking their heads against the brick walls of the county and the police who make so much play of keeping us safe.

    Report this comment

    Blackeye

    Tuesday, May 27, 2014

The views expressed in the above comments do not necessarily reflect the views of this site

Myrtle Turner teaches her last fitness class in Saxmundham after 52 years of teaching.

At 86 it’s not unexpected that all the members of Myrtle Turner’s fitness class would be younger than she is – but she is the session leader.

Search being co-ordinated at Jaywick for a missing kayaker

People are being urged to stay safe if they visit the seaside this summer after the death of a canoeist off the coast at Jaywick on Sunday.

The scene of a crash on the A134 near Sudbury

Two pensioners were airlifted to Addenbrooke’s Hospital after a crash in Sudbury left them in a life-threatening condition this afternoon.

East Anglian Air Ambulance

A woman suffered a broken leg after falling from a horse in Santon Downham, near Brandon.

Gemma Edgar and her son Noah with her brother Lee Relf, who has launched into fundraising for the Children's Eye Cancer Charity and is doing a sponsored cycle around Suffolk castles dressed as knights in honour of his nephew.

The uncle of a Colchester boy living with cancer is looking forward to embarking on a Knight Rider Challenge this weekend to raise funds for a charity that supports children with the disease.

Lady Of the Lake Pub

A former soldier who was suffering from post traumatic stress disorder (PTSD) when he punched a Suffolk pub landlord has walked free from court after his victim said he did not want him to go to prison.

A loo with a view in Pakefield

With so much to see and do on the Suffolk coast, a day trip is just never long enough - so why not make a weekend of it? Or even book a week-long holiday?

Most read

Great Days Out

cover

Click here to view
the Great Days Out
supplement

View

Most commented

HOT JOBS

Show Job Lists

Streetlife

Newsletter Sign Up

Sign up to the following newsletters:

Great British Life

Great British Life
MyDate24 MyPhotos24