Shrewsbury hospital admits missing serious injury on pensioner who later died after fall
A hospital trust has agreed it missed to spot a serious neck injury on a patient who died two weeks after falling.
John Robert Roberts, 84, of Colliery Road, St Martins, was admitted to the Royal Shrewsbury Hospital on February 20 this year, five days after a previous admission due to a fall.
His condition gradually deteriorated and he died on March 3.
An inquest into Mr Roberts' death, held at Shrewsbury Coroner's Court, heard that the medical cause of death was pneumonia with a spinal injury a secondary case due to a fall.
Senior Coroner for Shropshire and Telford, Mr John Ellery, said Shrewsbury and Telford Hospital NHS Trust (SaTH) had carried out its own serious incident investigation over the care and management of Mr Roberts.
He said that Mr Roberts was initially conveyed to the Royal Shrewsbury Hospital on February 15 following a fall at home. There was a three-hour 15-minute delay in offloading Mr Roberts from the ambulance.
He had difficulty moving his legs and a spine disc bulge was noticed, but a CT scan and X-ray found nothing abnormal.
Mr Ellery said the serious investigation carried out by SaTH looked at why his neck injury had been missed and would this have changed the outcome.
The conclusion was that if Mr Roberts had had an MRI scan the injury would have been seen and it would likely that the outcome would have been different.
The coroner said he was satisfied that recording a death by natural causes was not possible and that Mr Roberts' death had been, in hindsight, preventable and avoidable.
After members of Mr Roberts family welcomed the report Mr Ellery said he would prepare a written decision.
Following the hearing Hayley Flavell, Director of Nursing at The Shrewsbury and Telford Hospital NHS Trust (SaTH), said: “We would like offer our deepest condolences to the family of Mr Roberts. We are committed to improving the quality of care that we provide and lessons have been learned from Mr Roberts’s care.
"New measures include a face-to-face senior Emergency Department doctor review prior to referral for frailty assessments and relocation of the trauma and orthopaedic ward to the ground floor.”
