Betty Tadman
1 Feb 2021 · Coroner Sonia Hayes · Mid Kent and Medway
The coroner's concerns
1. missed diagnosis of pelvic fracture with internal bleeding
“Mrs [name redacted] had dementia and a long-term catheter who was admitted to hospital with a pre-alert for suspicion for urosepsis that was treated appropriately. However, urine dipstick tests were only positive for blood and consideration was not given to the circumstances in which she was found with a history of a fall.”
2. failure to recognise fracture injury
“Evidence was heard at the inquest that ambulance crew noted and handed over Mrs [name redacted] left leg was rotated but not shortened. Mrs [name redacted] could not stand or mobilise to use the commode in hospital. No consideration was given to a potential fracture injury.”
3. missed imaging for fracture detection
“Mrs [name redacted] was an elderly lady with a medical history of osteoporosis who fell from a standing height. No imaging was conducted on admission to hospital to establish if Mrs [name redacted] had sustained an injury.”
4. overreliance on symptom absence for DVT diagnosis
“Swelling in the calves gave rise to a suspicion of potential deep vein thrombosis and dalteparin was prescribed. Physical examination was over reliant on the lack of complaints of pain in a patient with dementia in the absence of imaging.”
5. failure to act on falling haemoglobin indicating internal bleeding
“There was no consideration of potential fracture or internal bleeding in the presence of dropping of haemoglobin and continued deterioration.”
6. lack of post‑death incident investigation and learning
“The Trust did not conduct a serious incident investigation following Mrs [name redacted] death when the post-mortem cause of death established a pelvic fracture with severe haemorrhage. Evidence heard at the inquest confirmed that this case was not discussed at the trust morbidity and mortality review or any other forum giving rise to concerns that lessons had not been learned.”