Joyce Nelson · Prevention of Future Deaths report

On THE 9TH April 2014 I commenced an investigation into the death of Joyce Nelson born 17th August 1919. The investigation concluded on the 21st August 2014 and the conclusion was one of Accidental Death. The medical cause of death was 1a Bronchopneumonia 1b Traumatic pelvic fractures, congestive cardiac failure due to atrial fibrillation, mitral and tricuspid regurgitation and pulmonary hypertension 11. Chronic kidney disease

Just before midnight on the 7th March 2014 she fell at her home address and fractured her pelvis in several places.

1. She was admitted to the Emergency Department at Stepping Hill Hospital shortly after midnight yet was not assessed by a doctor until 04.10 hours. I was told that the Department was fully staffed but there is a national shortage of Doctors specialising in emergency medicine.
2. Chest and hip X-rays were carried out but the results were not documented by the doctor who was simply too busy to do so.
3. Patient was to be discharged (even though it was later shown that she had a multi-fractured pelvis).
4. There were very considerable delays in reporting the imaging results, and I was told that this is due to a national shortage of Radiologists.

IT SEEMS THEREFORE THAT THERE IS A NATIONAL SHORTAGE OF THE VERY DOCTORS WHOSE PATIENT NEEDED, AND THIS SHORTAGE LED TO DELAYS IN TREATMENT WHICH WERE UNACCEPTABLE AND DELETERIOUS TO THE PATIENT’S HEALTH.