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Investigation and inquest
On 31st July 2013 I commenced an investigation into the death of Sandra Wordingham. The investigation concluded at the end of the inquest on 27th November 2013. The medical cause of death was: 1A Intracerebral Haemorrhage, and the conclusion of the inquest was that the deceased died from natural causes.
Circumstances of the death
Sandra Wordingham was a resident at Springbank nursing home, College Road, Barry. She had special needs and suffered from epilepsy. On 22nd July 2013 at around 23.30 hours care assistants found her in an unconscious state. They alerted the qualified nurses who tried to rouse her without success. It was assumed that she had had an epileptic fit and needed to sleep it off. She was put to bed unconscious. At 2.00 am she was checked again and was still unconscious. She was checked at 3.30 am, 5.30 am and 7.15 am and was in the same unconscious state. At 7.15 am paramedics were called who took her to Llandough hospital. She died in hospital on 26th July 2013
Coroner’s concerns
(1) Sandra Wordingham, was put to bed in the nursing home in an unconscious state after a suspected epileptic fit. In fact she had suffered a sudden primary intracerebral haemorrhage. No medical opinion was sought even though Sandra Wordingham remained unconscious throughout the night for a longer period than would be expected after an epileptic fit.
(2) While Sandra Wordingham suffered a profound insult which could not have been altered, had she suffered a gradual onset stroke then intervention could have been offered. In that event early medical attention would have saved her.
(3) Residents in an unconscious state who are treated in future in the same way as Sandra Wordingham may be at risk of unnecessary death or injury.
Information checked against the published report and official responses