A 95-year-old man who fell and hit his head at a nursing home died following a series of failures in his treatment at a hospital in Birmingham.
After hearing evidence about the failures city coroner Aidan Cotter said he would be raising his concerns with the chief executive of the Heart of England NHS Foundation Trust.
“I will be saying he needs to make sure that the situation does not arise again,” the coroner said.
He said Arthur Burley had been living at the Priory Nursing Home, in Shirley, for about three years. The coroner said that his mind was still bright but following a previous fall which resulted in a fracture his mobility had been reduced.
In the early hours of April 17, 2007, he said, he suffered another fall in his room and it was obvious that he had hit his head on something.
He was taken to Heartlands Hospital and was returned to the nursing home later that morning.
However, his condition deteriorated and after being taken to Solihull Hospital he died on April 20. A post mortem revealed that the main cause of death was a bleed to the brain.
The coroner said it must have been obvious there was a real risk of a bleed to his brain and that the failures at Heartlands Hospital included not giving the pensioner a CT scan.
He said Mr Burley should have been kept in for observation and that the medication he was taking, the blood thinning agent Warfarin, should have been stopped immediately.
The coroner said when Mr Burley was admitted to Solihull Hospital the notes from that morning’s admission to Heartlands could not be accessed even though the two hospitals were part of the same NHS Foundation Trust.
Even when the bleed was identified and fresh plasma ordered it was not given to Mr Burley for another 23 hours.
Advice was also sought from a neurosurgeon but was not received for over 12 hours, said the coroner.
“There is no doubt in my mind that failures at Heartlands Hospital made his survival much less likely than it would have been otherwise,” he said.
However, in recording that Mr Burley died as a result of a fall he said he could not be certain that the failures in his treatment caused his death.