Mrs Constance Pridmore · Prevention of Future Deaths report

On 26th May 2015 an investigation was commenced into the death of Mrs Constance Pridmore, aged 82 years old. The investigation concluded at the end of the inquest on 16th March 2016. The conclusion of the inquest was accidental death. The medical cause of death was:

1.(a) Left side haemothorax
(b) Fractured ribs

Mrs Pridmore was living independently at home in Barrow-in-Furness at the time she accidentally fell on 3rd May 2015. She was admitted to Furness General Hospital; was the subject of a chest x-ray and head CT scan; diagnosed with pneumonia and admitted to a medical ward for administration of intravenous antibiotics.

Mrs Pridmore’s condition, whilst initially stable for a couple of days, deteriorated significantly on the evening of 6th May 2015. Her chest x-ray was reviewed by a consultant anaesthetist and several rib fractures were noted; which had not been identified on admission by Accident & Emergency staff.

Mrs Pridmore died on 7th May 2015 from a haemothorax associated with the fractured ribs during a procedure to insert a chest drain. Over 2.3 litres of blood was lost from the chest drain from her lung which had accumulated undetected over the previous days following her fall.

(1) It was confirmed in evidence by Consultant Radiologist ████████ that:

a) X-rays undertaken on admission to the Accident & Emergency ward at Furness General Hospital are not immediately reviewed by a radiologist, but are assessed by the requesting physician.

b) The X-rays are eventually reviewed by a radiologist on a non-urgent basis when capacity in the system permits. In the case of Mrs Pridmore, her x-ray was reviewed on 11th May 2015, 8 days after being taken and 4 days after she had died.

c) X-rays are not reviewed sooner by a radiologist due to a shortage of available radiologists within the Trust.

(2) It was confirmed in evidence by Consultant Physician ████████ that:

a) If Mrs Pridmore’s x-ray had been reviewed by a radiologist on 3rd May 2015, it is likely that the rib fractures and associated haemothorax would have been identified and that Mrs Pridmore would have been cared for differently.

b) on the balance of probabilities, the outcome for Mrs Pridmore would have been the same due to her age and the nature of her injury. However the failure in identifying the fractures denied Mrs Pridmore the opportunity of a more appropriate course of treatment (e.g. pain management and symptom control) and the possibility, all be it remote, of a different outcome

(3) It was confirmed in evidence by independent Consultant Radiologist, ████████
████████ that:

a) the rib fractures were only discretely visible on the x-ray and would have required a trained radiologist to identify them

b) The shortage of radiologists within the Morecambe Bay trust which prevented Mrs Pridmore’s x-ray from being reviewed by a radiologist sooner is reflective of a critical shortage of radiologists in the U.K.

c) There are presently approximately 400 vacant consultant radiologist posts unfilled in the U.K.

d) the target set in ████████2013 report entitled “NHS Services, Seven days a Week” (Paper NHS121315) for urgent x-rays of inpatients to be completed (including the reporting by a radiologist) within 12 hours is far from being achieved both locally by Morecambe Bay Trust, but also nationally by all Health Trusts. This is due in part to a general increase in the use of scans and x-rays as diagnostic aids, but mainly due to the acute shortage of radiologist who are available and trained to interpret the relevant data accurately and in a timely manner. The Keogh targets whilst intended to become reality by the end of 2016/17 are becoming a more distant ideal than a realistically approaching target.

It is probable that current delays on both a local and national basis in obtaining in a timely manner, accurate radiologist reports of x-rays and CT scans taken for diagnostic purposes, creates a foreseeable risk that further deaths may well arise as a consequence.

Locally, a review of your procedures with regard to the assessment of x-rays is required and nationally, a review into the implementation of the recommendations of the Keogh report is likely to be necessary.