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Investigation and inquest
On 8.10.25, I concluded the inquest into the death of Brian Ingram aged 85 who died in Royal Cornwall Hospital on 17/5/24.
I recorded the cause of death as:
1a) Ischaemic heart disease with cardiomegaly;
II) Diabetes, Chronic Kidney Disease, Dementia, Osteoporotic hip fracture.
I recorded a conclusion of Accident.
Circumstances of the death
Brian was an 85-year-old man with a past medical history that included vascular Parkinsonism and dementia. On 11/5/24, he fell in his garden and suffered injury. The 111 service was called and an ambulance requested. After a delay of several hours, a private ambulance from LML conveyed Brian to Barncoose Minor Injuries Unit. A member of the family accompanied him but was asked to remain in the ambulance while Brian was clerked in. A Patient Clinical Record was not provided to staff. No physical assessment was conducted by the MIU staff who wrongly assumed Brian had been assessed by paramedics when the ambulance staff were Emergency Care Assistants. Brian had an x-ray of his knee but not his hip despite reporting groin pain and his family noting that one leg appeared shorter than the other. Brian was discharged. On 15/5/24, Brian was admitted into Royal Cornwall Hospital and had an x-ray that
confirmed he had fractured his hip. He had an operation to fix the fracture but deteriorated and died in the hospital on 17/5/24.
Coroner’s concerns
1) The family was under the impression that Brian was attended upon by paramedics rather than ECAs. It was accepted in evidence that proper introductions should be made when meeting a new family to include confirmation of a staff member’s clinical grade.
2) Brian had dementia and so a family member accompanied him to the MIU. That family member was, however, asked to remain in the ambulance while Brian was clerked in. This caused or contributed to an omission to record groin pain as a presenting complaint. In evidence, it was suggested this was a hang over from COVID but it appears a practice that may need to be re-visited, especially where a patient presents with dementia and may not be able to provide a full or accurate history.
3) The inquest was told that it will ordinarily be a SWAST ambulance that attends the MIU and there is a process whereby an ACRF can be sent electronically with the relevant past medical history. On this occasion, an LML ambulance attended whose staff work from written Patient Clinical Records. There was a conflict in the evidence as to whether a PCR was provided to MIU staff. One had to be subsequently requested by CPFT to review what had happened on the day. It may be appropriate to review how information is shared between different organisations.
4) Brian was seen by a triage nurse who ordered a knee x-ray only.
5) The nurse clinician was asked to review the x-ray only. There did not appear to have been any check as to whether Brian needed to be conveyed to RCHT which may have been appropriate if the complaint of groin pain had been noted.
6) The nurse clinician did not know the ambulance staff were ECAs and had wrongly assumed they were paramedics and had conducted their own assessment.
7) The nurse clinician did not conduct his own physical assessment or speak to the available family member to confirm the relevant history and presenting complaints.
Information checked against the published report and official responses