Mrs Elizabeth Glen Self · Prevention of Future Deaths report

In November 2017 I commenced an investigation into the death of Mrs Elizabeth Glen Self. The investigation concluded following an inquest in June 2018 where the narrative conclusion set out that:

Mrs Self was admitted to hospital on 11th April 2017 following a heart attack. The court finds it more likely than not the she would have survived this episode.
Unfortunately Mrs Self suffered a serious fall in hospital when she became entangled in a line attached to her left leg, this left her with serious injuries which were not immediately recognised. Necessary scans and x-ray examinations were ordered some hours later but did not take place for another nine hours or so.
The court has closely considered these most regrettable delays but the expert advice is that a faster response either in investigation or transfer to Sheffield would probably not have saved Mrs Self’s life.

The circumstances of the death are set out in the narrative conclusion shown above. In addition I attach a copy of my closing remarks which is just a single sheet.

In summary, this lady with severe heart disease suffered a fall in hospital. She was unlikely to survive from that point onwards but there was a delay in dealing with two x-ray requests and one CT request of more than thirteen hours.

a) A moderately senior doctor had put in not one but two x-ray requests that had to be rejected which is suggestive of a lack of necessary training

b) A valid CT request had laid unattended for a full morning, the reasons for which were never established but the hospitals own investigation report team formed an impression of a breakdown in communications.

c) The overall circumstances were such that neither requests was actually completed until more than thirteen hours after what was a significant fall. The inquest found this to be a criticism of the system then in place rather than of particular individuals.

In essence my concern is that those inspecting hospitals in other places should include in their programme establishing that senior staff do actually know how to make a proper x-ray request which will not therefore be rejected and checking systems to ensure that x-ray and CT requests cannot go for a period of hours without resolution.