Marjorie Booth · Prevention of Future Deaths report

On 21st October 2015 I commenced an investigation into the death of Marjorie Booth ob 27th March 1924. The investigation concluded on the 2nd March 2016 and the conclusion was one of Accidental Death. The medical cause of death was 1a Respiratory and cardiac Failure 1b Hospital acquired pneumonia 1c Acute stroke 11. Left hip replacement, atrial fibrillation, moderate to severe mitral regurgitation, hypertension.

On the 21st September 2015 she fell at her home address. She tripped over the tail of a coat which she was carrying and fell at the bottom of the stairs. She was taken to hospital where she was examined and had an X-ray taken of her hip but the staff failed to note that she had an impacted fracture of the hip. She returned to the hospital the following day when a CT scan was performed, the fracture was identified and was operated upon. She then sadly declined over the next days and died on the 19th October.

1. I was told that a CT scan is not routinely asked for in these circumstances, even though it is really the only way to be sure that there is no impacted or un-displaced fracture, because of the risk of exposing the patient to additional levels of radiation. The doctor giving this evidence agreed with me that the minimal risk of the radiation (in a patient over 90 years old) did not compare with the considerable risk of missing such fractures.

2. Can the Trust explain why there is apparently a policy not to perform scans in such circumstances and whether in fact this policy could be amended.