Joseph Brindley · Prevention of Future Deaths report

On 18th May 2020 I commenced an investigation into the death of Joseph Brindley. The investigation concluded on the 13th November 2020 and the conclusion was one of Narrative: Died from the consequences of an intracranial bleed, exacerbated by anticoagulation. The medical cause of death was 1a Intracranial bleed on a background of anticoagulation, II Ischaemic Heart Disease, Atrial Fibrillation, Chronic Kidney Disease, Hypothyroidism

On 11th March 2020, Joseph Brindley was admitted to Tameside General Hospital following a fall. He had a significant pleural effusion. He also had rib fractures, which were not identified on a CT scan or in X-rays, although they were visible in two X-rays. He was subsequently discharged from Tameside General Hospital. He was breathless at home and returned to the Emergency Department on a number of occasions and there was a suspected pulmonary embolism identified on one occasion. That was excluded with a CT pulmonary angiogram although the rib fractures were identified at that point. On 16th May 2020, he was found unresponsive downstairs at his home address. On admission to hospital, a CT scan identified a catastrophic bleed to the brain, exacerbated by anticoagulation. He died at Tameside General Hospital on 16th May 2020.

The inquest heard that the CT scan and the X-rays were said to have been examined carefully. However, the fractures were not identified. Availability of radiologists due to a shortage of qualified radiologists locally and nationally meant that radiographers as well as radiologists were involved in the reviews that did not identify the fractures. The final review where the fractures were not picked up was said to have included careful comparison with the earlier X-ray. The Trust has made HMC aware of review processes which seek to enhance clinical skills and avoid errors. However, it is unclear what steps have been taken to tackle and avoid the specific concerns that arose in this case where 3 qualified members of staff did not recognise the injury.