On 30 December 2015, commenced an investigation into the death of Mrs Marie Rollason. The investigation concluded at the end of the inquest on 19 February 2016. The conclusion of the inquest was the deceased died by way ofnatural causes contributed to by neglect. The cause of death was: Ia. Pulmonary Embolism

Mrs Rollason was a 43 year old woman who sustained a head injury during a fall in her bathroom at her home on the 19 December 2015. She was admitted to New Cross Hospital Emergency Department Wolverhampton at around 11.45pm. The laceration was sutured and computerised topography (CT) scan performed. The CT scan did not show any evidence of fractures or haemorrhages_ The injury was recorded as a laceration to the right side of forehead after a fall She was later discharged home the following morning on the 20 December shortly before 4am. She was provided with a leaflet advising that if she had any further loss of consciousness then she should seek medical attention. Over the course of the next several days she had & number of periods of loss of consciousness and was re-admitted back to the Accident and Emergency Department on the 23 December after she collapsedlfainted at her GP's surgery. She was examined at the same Hospital and her observations recorded An electrocardiogram (ECG) trace was also recorded. This revealed an abnormality in the trace which can be indicative of changes that occur during pulmonary embolism. However the Junior Doctor recorded the ECG trace 'was okay" and she wasn't kept in for further observation but instead discharged and advised that if the dizziness/fainting spells continue then she should be referred to a cardiologist via her GP_ She continued to have fainting spells and loss of consciousness at home and then on_the_29_December_collapsed_again_ at_her_GP's_surgery_and_sadly: [ILI: PROTECT]

despite resuscitation attempts she died