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Joyce Nelson

Ref: 2014-0397 Date: 9 Sep 2014 Responses identified: 0 / 1 View PDF

Significant delays in doctor assessment and imaging results in the Emergency Department, caused by national shortages of emergency medicine doctors and radiologists, led to misdiagnosis and potential unsafe discharge.

Date 9 Sep 2014
56-day deadline 4 Nov 2014
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Significant delays in doctor assessment and imaging results in the Emergency Department, caused by national shortages of emergency medicine doctors and radiologists, led to misdiagnosis and potential unsafe discharge.
View full coroner's concerns
_ She was admitted to the Emergency Department at Stepping Hill Hospital shortly after midnight yet was not assessed by a doctor until 04.10 hours: was told that the Department was fully staffed but there is a national shortage of Doctors specialising in emergency medicine_ Chest and hip X-rays were carried out but the results were not documented by the doctor who was simply too busy to do so. Patient was to be discharged (even though it was later shown that she had a multi-fractured pelvis)- There were very considerable delays in reporting the imaging results, and was told that this is due to a national shortage of Radiologists_

Report sections

Investigation and inquest
On THE 9TH April 2014 commenced an investigation into the death of Joyce Nelson born August 1919. The investigation concluded on the 21s August 2014 and the conclusion was one of Accidental Death: The medical cause of death was Ia Bronchopneumonia 1b Traumatic pelvic fractures, congestive cardiac failure due to atrial fibrillation, mitral and tricuspid regurgitation and pulmonary hypertension
11. Chronic kidney disease
Circumstances of the death
Just before midnight on the 7th March 2014 she fell at her home address and fractured her pelvis in several places.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action.

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Report details

Reference
2014-0397
Date of report
9 September 2014

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Nov 2014.

Sent to

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.