Else Merete-Harvey Samuel · Prevention of Future Deaths report

On the 25th of February 2013 I commenced an investigation into the death of Else Merete-Harvey Samuel, aged 89. The investigation concluded at the end of the inquest on the 21st of May 2014. The conclusion of the inquest was that Mrs Harvey-Samuels “Died from complications following a fall and pelvic fracture, contributed to by significant pre-existing natural disease.” The cause of death was found to be 1a Bronchopneumonia, Bone marrow and fat embolism and anaemia due to 1b Fall with pelvic fracture and haematoma, with contributory causes of Recent organising myocardial infarction and Coronary artery atherosclerosis. There were matters that became evident which gave cause for concern.

Mrs Harvey-Samuel was admitted to the West Suffolk Hospital on the 15th of February 2013 following a fall at her residential home which resulted in groin pain, and the possibility of a hip or pelvic fracture was considered by the GP who referred her to hospital. Radiographs at that time did not reveal any fractures. Mrs Harvey-Samuel’s condition was complicated by other medical issues and pain control remained a problem. Repeat radiographs were requested out of hours because of continuing problems but the radiographer questioned the request and some views were not repeated, including the pelvis. The clinical history accompanying the request had not given the whole picture and the expected communication between senior clinician and radiologist, after the radiologist declined to do some views, did not occur. Following Mrs Harvey-Samuel’s subsequent death a pelvic fracture was found at post mortem, along with significant natural disease. A clinical incident was raised and investigated following the x-ray problems but this did not answer all of the issues raised by the incident. While it is accepted that there would have been no active management had the existence of the pelvic fracture been established in life, and the tragic outcome was still likely to have occurred, an accurate diagnosis would have assisted the clinical management greatly and, without attention to the issues raised by this very sad situation, there remains a risk of other fatalities occurring if accompanying clinical histories are not complete and potentially significant radiographs are not taken as a result.

(1) Doctors requesting radiographs or other imaging investigations (whether out of hours or not) must include sufficient clinical information to explain why the investigation is indicated to avoid the request being rejected, and also to inform the radiologist who reports on the subsequent images what the relevant clinical history was.
(2) In the event of further need for justification of an out hours investigation, discussion between senior clinician and senior radiologist should take place and be documented.
(3) In any post untoward incident investigation, the system for determining the correct level of post event analysis, and the investigation itself, must be sufficiently robust to establish fully what occurred and to take any statements required as near to the time of the event as possible so as to identify any lessons that need to be learned.