Alfred Grimshaw
PFD Report
All Responded
Ref: 2016-0387
All 1 response received
· Deadline: 23 Dec 2016
Coroner's Concerns (AI summary)
A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy reviews were documented but not conducted, leading to discharge with unaddressed mobility issues.
View full coroner's concerns
In the circumstances it is my duty to report to you the MATTERS OF CONCERN being as follows: [C44780/2016 Alfred GRIMSHAW (Deceased) day The May
1. On being assessed in the emergency department on the 26t despite the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise no X-ray was carried out in order to rule out the possibility of a fracture to his hip. On 27th 2016 an X-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction: Although that was an X-ray of the abdomen it covered part of the right hip, which disclosed significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film: Despite the fracture being disclosed on the X-ray, the report made no reference to it: On the 27th request was made for physio and 0 T review which was clearly documented, there was however no evidence that physio or 0 T was carried out prior to discharge_ On the discharge summary that was printed on the 28t May 2016 at 16.21 is a handwritten note "Patient off his legs. Pain ++ right hip ad during movement: Physio advises x-ray to exclude fracture prior to any physiotherapy That handwritten note iS not signed or dated
1. On being assessed in the emergency department on the 26t despite the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise no X-ray was carried out in order to rule out the possibility of a fracture to his hip. On 27th 2016 an X-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction: Although that was an X-ray of the abdomen it covered part of the right hip, which disclosed significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film: Despite the fracture being disclosed on the X-ray, the report made no reference to it: On the 27th request was made for physio and 0 T review which was clearly documented, there was however no evidence that physio or 0 T was carried out prior to discharge_ On the discharge summary that was printed on the 28t May 2016 at 16.21 is a handwritten note "Patient off his legs. Pain ++ right hip ad during movement: Physio advises x-ray to exclude fracture prior to any physiotherapy That handwritten note iS not signed or dated
Responses
Action Taken
The Trust has strengthened communication processes for complex frail patient discharges, with emphasis on the Multidisciplinary Team and improved information transfer between primary and secondary care. The case has been used as a learning case for junior doctors. (AI summary)
The Trust has strengthened communication processes for complex frail patient discharges, with emphasis on the Multidisciplinary Team and improved information transfer between primary and secondary care. The case has been used as a learning case for junior doctors. (AI summary)
View full response
Dear Mr Singleton Re: Regulation 28 report in relation to death of Mr Alfred Grimshaw am writing in response to your Regulation 28 letter of 28"h October 2016 in which you identify several specific concerns relating to the care of specific patient. apologise for the in replying; this is due in part to exceptional clinical workload and delays in obtaining case notes The case involved a failure to diagnose fracture of the femoral neck during the initial admission of this patient despite a number of opportunities to do so. This patient was subsequently re-admitted (four days after discharge) and received the correct surgical management but unfortunately suffered post-operative complications and died, will deal with each of your concerns in the order you raise them: The failure to perform an x-ray of the hip given the history and clinical findings. have reviewed the Emergency Department notes of this patient and the clinical picture presented to the Doctor did not suggest a fractured femoral neck as the patient was moving all limbs and not complaining of specific hip pain. An alternative diagnosis to explain the reduced mobility was felt to be more appropriate: 2, The x-ray report of 27/h May (abdominal X-ray to exclude intestinal obstruction) failed to report the evident right hip fracture The Radiologist who undertook this report is currently under restricted practice , and subject to a clinical review: am unable to comment further on this matter but specific measures have been in place to ensure that the risk of further errors is reduced 3 & 4. The processes around communication relating to discharges of complex frail patients has been significantly strengthened in the past six months with specific emphasis upon the role of the Multidisciplinary Team: There have also been developments between primary and secondary care to ensure that discharge documentation and transfer of information is improved. Safe Personal Effective INVESOPRS the delay put
would point out that initial statement_ stated that the discharge summary print out that you refer to was printed on 15t June, whereas your letter suggests 28th May: Having reviewed the case notes if the case that the letter printed out on 28" does not contain a handwritten note: It is the copy printed on 1* June which does. have been unable to identify who wrote this nole_ As a result of the receipt of this Regulation 28 notice this case has been used as learning_case for teaching of Junior Doctors and used in feedback meetings to the Ward Team involved.
would point out that initial statement_ stated that the discharge summary print out that you refer to was printed on 15t June, whereas your letter suggests 28th May: Having reviewed the case notes if the case that the letter printed out on 28" does not contain a handwritten note: It is the copy printed on 1* June which does. have been unable to identify who wrote this nole_ As a result of the receipt of this Regulation 28 notice this case has been used as learning_case for teaching of Junior Doctors and used in feedback meetings to the Ward Team involved.
Sent To
- East Lancashire Healthcare NHS Trust
Response Status
Linked responses
1 of 1
56-Day Deadline
23 Dec 2016
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the gth of June 2016 I commenced an Investigation into the death of Alfred Grimshaw aged 93 years: The Investigation concluded at the end of the Inquest which was heard on the 25th day of October 2016. conclusion of the Inquest was that Alfred Grimshaw had died from Natural Causes contributed to by a fall followed by surgery.
Circumstances of the Death
On the 26th 2016 Alfred Grimshaw had an unwitnessed fall at the residential care home ad was admitted to the Royal Blackburn Hospital: On assessment in the Emergency Department it was noted that since the accident he had been unable to mobilise and that because of his dementia it was not possible to take a history from him. He was admitted onto the acute medical unit but then discharged on the 28th May back to the care home: He was then re-admitted on the 1s June 2016 when X-rays revealed that he had a fractured hip: He underwent surgery but died from bronchopneumonia on the 6t June 2016.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.