Margaret Theresa CORRIGAN · Prevention of Future Deaths report

On 26 March 2013 I commenced an investigation into the death of Margaret Theresa Corrigan who was born on 31 August 1924. The investigation concluded at the end of the Inquest on 6 September 2013 and the conclusion of the Inquest was that she died as a result of an Accidental Death. The medical cause of death given was 1a) Cerebellar and inferior parieto-occipital infarct due to 1b) Vertebral artery dissection due to 1c) Peg fracture and under Part 2: Clostridium Difficile infection.

The circumstances of the death were that on 18 January 2013 the deceased fell on the stairs at her home address and fractured her odontoid peg.

1. Communication between and among medical and nursing staff at your hospital was ineffective and lacked clarity.

2. The patient was seen in the Emergency Department and it was agreed in evidence that the fracture ought to have been diagnosed at that time but it was not, thus meaning the patient was left for a further two days in additional pain and at risk of further spinal damage.

3. The patient remained on the orthopaedic ward when she was suffering at that stage from medical problems and ought properly to have been transferred to a medical team.

4. Whilst she was an in-patient in the hospital, she was issued with an out-patient appointment to attend an orthopaedic clinic.