John Robert Maltby Worthington · Prevention of Future Deaths report

On 18th July / 2017 I commenced an investigation into the death of John Robert Maltby Worthington. The investigation concluded at the end of the inquest on 28th June 2018. The conclusion of the inquest was:-
The deceased was a 67 year old male. During the late evening of 3rd April 2017 he was carrying a suitcase up the stairs at his home address when he lost his balance, falling backwards. He was able to call for an ambulance. Paramedics arrived at 8.36pm. The deceased was taken to the Royal Stoke University Hospital, Stoke-on-Trent where he was treated for a head injury. He said he had fallen from 4 steps in height. Pain in his back and neck were noted but other observations were within normal parameters. An X-ray and scan were not considered to be necessary. He declined to stay in hospital overnight and was discharged home the same evening. On 5th April 2017 the deceased complained to his daughter of a sore chest saying he had fallen from the top of the stairs. He was relatively immobile and experienced worsening chest and back pains over the following 2 weeks. On the 12th April 2018 he called an ambulance again complaining of chest pains but declined to go to hospital. He contacted his GP to review the paramedics ECG. The doctor asked him to call to see her and made an appointment for him the next day. A further ECG was not considered necessary. Examination revealed tenderness in the lower back region. A full set of observations were not recorded and no further investigations were considered necessary. On 16th April 2017 the deceased called for an ambulance and was taken to the Royal Stoke University Hospital with ongoing back pains. He was subsequently found to have L1 fracture and transverse process fractures L2-L4, healing left 11th and 12th rib fractures and bi-basal consolation. He was treated for pneumonia and a spinal abscess was drained. He deteriorated and died in the Royal Stoke University Hospital on 29th June 2017. A post mortem examination gave the cause of death as bronchopneumonia, osteomyelitis of the spine and traumatic spinal fracture.
The conclusion at the inquest was that the deceased died from an accidental fall. He had been examined by clinicians but his injuries remained undiagnosed for a two week period.

Reason: fall with multiple fractures.

(1) The deceased attended A&E on the 4th April 2017.He had a very significant head injury 10 cm long requiring 15 stitches and exposing the skull. He had fallen downstairs. He gave a history of a fall from 4 steps. He complained of back and neck pain. Examination of the spine did not reveal any tenderness and other observations were within normal parameters. Further investigations were considered unnecessary and the NICE guidelines were considered. . The deceased’s presenting complaint appeared to fall within a grey area/borderline decision warranting further investigation by way of x-ray/scan. A decision was made not to do this. He later died from injuries sustained in that fall. It is understood that nationally work may be underway to reduce the threshold in such borderline cases. It may be of benefit to future patients for this matter to be further considered.
(2) Mr Worthington persistently complained of back pain. He saw his GP on the 13th April 2017. He was tender on his back. No further investigation was recommended and a full set of observations were not taken or recorded. He presented to the hospital 3 days later with irreversible bronchopneumonia. A full set of observations may have given an earlier indication of the developing problem.