Howard Winter · Prevention of Future Deaths report

On the 21st September 2017 I commenced an investigation into the death of Howard Winter aged 85. The investigation concluded at the end of an inquest on 1st February 2018. The medical cause of death was 1a. Hospital Acquired Pneumonia, 1b C5-6 vertebral fracture with cord injury, alongside subdural bleeding in the setting of a person with ankylosing spondylitis, 1c Recurrent Falls & 2. Vascular Dementia. The conclusion of the inquest was Accidental Death.

The deceased was a resident at the Daffodils CH, Merthyr Tydfil. He suffered from vascular dementia & had frequent falls. On 23.8.17 he fell in his room, sustained a serious head injury & was taken to PCH, Merthyr Tydfil. On 11.9.17 he was diagnosed with a fracture spine. He developed pneumonia & died there on 16.9.17

When Mr Winter attended at A & E on 23 & 26.8.17, he was diagnosed with a subdural haematoma following a CT scan head. It was not until after a CT scan of his spine was undertaken on 11.9.17 that he was diagnosed with a cervical spine fracture. The question arose as to whether, & following his initial presentation on 23.9.17 & admission on 26.8.17 there was any evidence of symptoms of neck pain which could have given rise to earlier investigations into, & possible earlier diagnosis of the cervical spine fracture.

████████ gave evidence at the Inquest that on the 26.8.17 an auxiliary nurse had recorded in the nursing notes – “pain in neck/back – unable to score”. There was no evidence – written or otherwise, to demonstrate an escalation of this finding to a doctor for re-assessment, investigation & diagnosis.

████████ evidence to the Inquest was that this ought to have occurred.

Whilst this apparent absence of escalation may not necessarily have affected the outcome for Mr Winter, were it to be repeated now, or in the future, the outcome for the patient involved could be potentially causative of/contribute towards death/adverse outcome.