Donald Charles Brown · Prevention of Future Deaths report

On the 8th March 2021 I commenced an investigation into the death of Donald Charles Brown. The investigation concluded at the end of the inquest on the 13th December 2022. The conclusion of the inquest was a narrative conclusion. The medical cause of death was 1A Aspiration pneumonia, 1B C2 fracture dislocation.

Donald Charles Brown “Donald” was an 87 year old man who suffered a fall at home on the 31st January 2021. He was taken to hospital and underwent CT examination. No fractures were reported. Following further investigations he was discharged home. Following discharge Donald continued to experience neck pain and difficulty swallowing. He was readmitted to hospital on the 26th February 2021 and was treated for aspiration pneumonia. Further CT imaging demonstrated that he had suffered a displaced fracture of the C2 vertebra with spinal cord compression. This injury had been sustained in his fall on the 31st January. It was visible on the CT imaging taken on that day. However it was not reported. It is likely that the severity of this injury led to his swallowing difficulties and caused aspiration pneumonia. Neurosurgical opinion was sought and advised against operative intervention. Donald’s condition thereafter steadily deteriorated and he passed away at 08.15 hours on the 4th March 2021.

1. The significant understaffing of the Radiology department at the hospital.
2. The national shortage of radiology trainee posts.
3. The expectation that the reporting of all scans including non urgent, will be done within an hour.
4. The appointment of call handlers to triage calls to reduce the demands on the radiologists’ time has been delayed due to cost.