On 29 July 2015 commenced an investigation into the death of Mrs Mary Myfanwy Hollands, aged 98. The investigation concluded at the end of the Inquest on 3 December 2015 The conclusion of the Inquest was that Mrs Hollands died from natural causes_ The medical cause of death was I(a) Ischaemic Heart disease Pneumonia: Old Age, Dementia_

(1) Mrs Hollands was a 98 year old lady with dementia She sustained an unwitnessed fall at the nursing home where she lived and was transported to Ysbyty Gwynedd by ambulance_ She complained of pain in her left shoulder and left hip. Xrays where taken of the shoulder and Both of these were examined and the junior doctor who reviewed the X ray of the hip could not see bony injury: It was believed that Mrs Hollands was suffering from a UTI and she was given antibiotics Mrs Hollands was transferred to the medical team and was subsequently discharged_ (2) She then deteriorated over the next four weeks and washer less mobile than before the fall. She was admitted by ambulance to Ysbyty Glan Clwyd on 10 2015. As well as treating Mrs Hollands for dehydration and an infection an xray was taken of her left hip. This revealed a bony injury. Whilst this could not be dated it was confirmed that the result was the same as the xray taken weeks earlier. The bony injury had been missed on the previous occasion at Ysbyty Clwyd. Mrs Hollands was not strong enough for surgical intervention and she was discharged with advice that the hip injury be managed conservatively. Mrs Hollands continued to deteriorate and died on 27 July 2015 It is accepted that the hip injury was very difficult to identify. In these circumstances there is a safety netting system in place: A radiologist considers the X-ray and does a report within 48 hours which is sent to the Emergency Department: In Hollands' case the Consultant Radiologist reported that there was step in the cortex of the medial It neck raising_the_ possibility of an undisplaced fracture lf there are ongoing hip: any July four Glan Mrs symptoms, then a repeat film with a lateral is recommended. The paper copy of this report never arrived in the Emergency Department_ By the time the report was signed off Hollands had been discharged: The Emergency Department were not alerted to the possibility of the fracture_ Whilst the report was put on the PACS system there was no prompt for the Emergency Department staff to consider this_