On 23r November 2016 an investigation was opened into the death of Kristina CROSS aged 72_ The investigation concluded at the conclusion of the inquest on 12ih December 2017 . The conclusion of the inquest was: Mrs Cross died due to a sudden and catastrophic cardiac event; on a background of pre-existing cardiac changes and other medical conditions and (he trauma of a traumatically fractured right femur_delayed surgical fixation and post-operative complications CIrCUMSTANCES OF THE DEATH In brief summary the background is as follows: On 28ih August 2016 Kristina Cross was a 72 year old lady, admitted to the emergency department of the Royal Lancaster Infirmary by ambulance following a reported unwitnessed (all to her right side. On admission she underwent examination and assessment, presenting with recorded pain on her right shoulder, tenderness over the right pelvic area, and obviously deformed right wrist. She underwent a trauma CT scan which was reported as showing an old fracture of the right neck of femur; and a colles fracture of the distal ulna with dorsal angulation: Attempts were subsequently made to manipulate the right wrist, unsuccessfully and she was admitted for care. On 3r September 2016 Kristina Cross was referred for a further plain X-ray of her right hip, given reported ongoing pain: This was initially reviewed by a junior orthopaedic clinician, who re-iterated the opinion of an old fracture, and was further reported by radiology on 28lh September 2016 as the same: In the interim period, on 23r September 2016 Kristina Cross underwent a further X-ray of the right hip which was reviewed and reported as showing displaced fracture of the neck of femur. Kristina Cross underwent surgical fixation on 27lh September 2016, delayed by the initial and subsequent misdiagnoses of the right hip fracture_ Post-operatively Kristina Cross suffered wound complications , including wound infections and dislocations of the joint, identified on further CT scanning: Kristina Cross underwent further surgical fixation on Iglh November 2016. During the procedure it was reported that she suffered a sudden drop in blood pressure, that initially responded to therapy, however following transfer to the High Dependency Unit; she suffered further sudden deterioration at 05.30 on 20ih November 2016 from which she never_fully_recovered and_passed_away at08.30 on20h Coroner'$ Court; 2 Furaduy Courl Furuduy Drivc; Fulwood, Preston, Luncashirc; PRZ 9NB Tcl 01772 536536 Fux 01772 530752

November 2016 at the Royal Lancaster Infirmary: Ultimately the in diagnosing the fracture and progressing to surgical fixation significantly contributed to the death of Kristina Cross

In my opinion action should be taken t0 prevent future deaths and believe you have the power to take such action: Your RESPONSE You are under a to respond to this report within 56 days of the date of this report, namely by 28h February 2018. 1, the coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed.

On 28ih August 2016 Kristina Cross was a 72 year old lady, admitted to the emergency department of the Royal Lancaster Infirmary by ambulance following a reported unwitnessed (all to her right side. On admission she underwent examination and assessment, presenting with recorded pain on her right shoulder, tenderness over the right pelvic area, and obviously deformed right wrist. She underwent a trauma CT scan which was reported as showing an old fracture of the right neck of femur; and a colles fracture of the distal ulna with dorsal angulation: Attempts were subsequently made to manipulate the right wrist, unsuccessfully and she was admitted for care. On 3r September 2016 Kristina Cross was referred for a further plain X-ray of her right hip, given reported ongoing pain: This was initially reviewed by a junior orthopaedic clinician, who re-iterated the opinion of an old fracture, and was further reported by radiology on 28lh September 2016 as the same: In the interim period, on 23r September 2016 Kristina Cross underwent a further X-ray of the right hip which was reviewed and reported as showing displaced fracture of the neck of femur. Kristina Cross underwent surgical fixation on 27lh September 2016, delayed by the initial and subsequent misdiagnoses of the right hip fracture_ Post-operatively Kristina Cross suffered wound complications , including wound infections and dislocations of the joint, identified on further CT scanning: Kristina Cross underwent further surgical fixation on Iglh November 2016. During the procedure it was reported that she suffered a sudden drop in blood pressure, that initially responded to therapy, however following transfer to the High Dependency Unit; she suffered further sudden deterioration at 05.30 on 20ih November 2016 from which she never_fully_recovered and_passed_away at08.30 on20h Coroner'$ Court; 2 Furaduy Courl Furuduy Drivc; Fulwood, Preston, Luncashirc; PRZ 9NB Tcl 01772 536536 Fux 01772 530752

November 2016 at the Royal Lancaster Infirmary: Ultimately the in diagnosing the fracture and progressing to surgical fixation significantly contributed to the death of Kristina Cross