Gillian Baumgardt · Prevention of Future Deaths report

On 20/12/22 an investigation was commenced into the death of Gillian Baumgardt. The investigation concluded at the end of the inquest on 27th February 2024. The conclusion of the inquest was –

“Mrs Baumgardt died in part because she underwent wrong site hip surgery due to multiple errors occurring in the performing and reporting of a plain x-ray of her hip”.

Mrs Baumgardt was an elderly lady with dementia who fractured her right hip at home. She was admitted to your hospital and diagnosed correctly with a suspected fractured right hip.

However, in then performing and reporting the plain x-ray of her hips the following errors occurred –
Radiographer –
- Pre-exposure marker not placed in film field;
- Digital image inadvertently flipped;
- Digital image mislabelled left/right so that fractured side recorded as left;
- Cross on image denoting flipped not detected;
- Normal x-ray of left hip did not alert to error and did not lead to the affected side being double checked;
Radiologist –
- Normal x-ray of left hip attributed to error in labelling, rather than alerting to error and leading to the affected side being double checked.

As a result Mrs Baumgardt was referred to the orthopaedic team erroneously as presenting with a left hip fracture. Her age and dementia were such that she was difficult to assess clinically, the orthopaedic surgeons had no reason to suspect an error in labelling and she underwent surgery removing a healthy left femoral head.
The error was then appreciated and she had to undergo surgery to the right fractured hip 2 days later.
She died 6 weeks later having never regained her mobility. I found on the evidence that the wrong site surgery contributed to her death.

(1)Accurate radiology is essential to avoid wrong site surgery in elderly patients with dementia suffering hip fracture;
(2) There is no system requiring radiographers to ensure that pre-exposure markers are present in the x-ray field in all such patients;
(3) There is no system requiring radiologists to investigate inconsistency in the site of injury between different images and to alert clinicians to the inconsistency before finalising their report in all such patients.