Elsie Yvonne Taylor · Prevention of Future Deaths report

On 30/9/20 I commenced an investigation into the death of Elsie Yvonne Taylor dob 14/2/52. The investigation concluded at the end of the inquest on 7/12/20. The conclusion of the inquest was a short form conclusion of accident.

The medical cause for the death was established at post mortem as;

1a) Pneumothorax
1b) Rib Fractures
1c) Fall

2) COPD and IHD

(1). The deceased was a 68-year-old lady who had a past medical history of chronic obstructive pulmonary disease, atrial fibrillation on anti-coagulation and ischaemic heart disease with stents.

(2) On 15/9/20 she suffered a fall at her home address whereby she fell into a rose bush landing on her left-hand side. The fall was witnessed by a neighbour who helped her up. An ambulance was called approximately 1.5 hours later.

(3) Paramedics attended and recorded left sided pain and bruising. There was no loss of consciousness and she was advised to take painkillers, was referred to her GP (with a discharge notice left) and verbally informed to contact emergency services if the pain or her breathing should worsen.

(4) A further ambulance was called some 4 hours later where the deceased reported worsening pain and some difficulties breathing. A facial swelling was also noted with suspected allergic reaction.

(5) She was taken to hospital where she had a chest drain inserted and was presenting as peri arrest. A cardiac cause was ruled out but sadly she deteriorated and passed away later the same day.

(6) A post mortem revealed a pneumothorax and rib fractures consistent with a fall.

(1) The attending paramedic gave evidence at the inquest that on 15/9/20 the deceased had declined a hospital admission against advice due to concerns about Covid-19. This was not recorded in the EPR and the first time the family became aware of this was when a statement was received from the paramedic 2 days before inquest;

(2) The EPR did not record that the deceased had been advised to go to hospital nor that she understood any such advice and she was not asked to sign a disclaimer;

(3) There was no information left by the attending paramedic crew to reflect the decision of the deceased to decline admission or the advice given by paramedics. The family of the deceased were not present during the consultation and as a consequence they did not know what symptoms to look out for which might suggestion a deterioration in the condition of the deceased;

(4) There was no note left by the attending paramedic crew detailing the outcome of the consultation;

(5) The discharge notice left by paramedics contained her observations only and the wording suggested she had been referred to her GP as an alternative to a hospital admission;

(6) The deceased lived alone and suffered with COPD and IHD. No attempt was made to contact the GP of the deceased or a family member despite the fact it was known that the deceased lived alone (it was noted in the EPR).