Skip to content
recurance

Alfred Grimshaw

28 Oct 2016 · Coroner Michael Singleton · Blackburn, Hyndham and Ribble Valley

The coroner's concerns

  1. 1. failure to obtain hip x-ray after unwitnessed fall

    “On being assessed in the emergency department on the 26" May, despite the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise no x-ray was carried out in order to rule out the possibility of a fracture to his hip”
  2. 2. failure to report fracture on abdominal x-ray

    “On the 27" May 2016 an x-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction. Although that was an x-ray of the abdomen it covered part of the right hip, which disclosed a significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film. Despite the fracture being disclosed on the x-ray, the report made no reference to it”
  3. 3. unsigned undated discharge note with physiotherapy advice

    “On the discharge summary that was printed on the 28" May 2016 at 16:21 is a handwritten note "Patient off his legs. Pain ++ right hip and during movement. Physio advises x-ray to exclude hip fracture prior to any hysiotherapy." That handwritten note is not signed or dated”

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error

Alfred Grimshaw · Recurance