Mr Frank Hayward · Prevention of Future Deaths report

On the 21 December 2017, I commenced an investigation into the death of Mr Frank Hayward. The investigation concluded at the end of the inquest on 9 March 2018. The conclusion of the inquest was a short narrative conclusion of:

Accidental death contributed to by neglect.

The cause of death was:

1a Raised Intracranial Tension
Subdural Haematoma And Fracture Type II Odontoid Peg 2
c Fall

i) On the 12 November 2017, Mr Hayward had a fall at home and sustained an odontoid peg fracture and subdural haemorrhage. His past medical history included: dementia, atrial fibrillation on rivaroxaban, chronic lymphocytic leukaemia and ischaemic heart disease.

ii) He was admitted to Sandwell Hospital and a CT scan failed to initially identify the haemorrhage. In addition there was an inadequate examination to identify the fracture.

iii) Anti-coagulation medication was stopped two days later on the 14 November 2017. His condition declined further and he complained of worsening neck pain and drowsiness.

iv) A further urgent CT scan was requested on the 19 November and wasn't actioned until the 22 November which then revealed the bleed and also the fracture.

v) He wasn't deemed suitable for surgical input and managed conservatively.

vi) There were also delays in obtaining a suitable cervical collar for his neck and the family had to source and pay for one privately. This was due to staff sickness absence and relocation of the service department.

vii) He sustained a further fall in hospital with no further recorded injuries on the morning of the 26 November 2017.

viii) Sadly, his condition continued to decline further and he died on the 10 December 2017.

1. Evidence emerged during the inquest that there were failures to correctly assess and diagnose his injuries in the Emergency Department and there were missed opportunities to have him reviewed by Trauma and Orthopaedics team sooner.

2. There was also evidence of poor systems in place in providing a collar for the patient and poor communication between the Orthotics Department and ward based staff. In addition there was a significant delay in obtaining an urgent CT scan.