Susan Elliott
6 Aug 2018 · Coroner Derek Winter · Sunderland
The coroner's concerns
1. ignored x-ray leading to missed fracture
“The orthopaedic surgeon in his evidence confirmed that the x-ray of 4"" August 2017 was "reported on and ignored”
2. absence of CT scan before discharge
“No CT scan was undertaken prior to discharge on 9" August 2017, so there was no definitive diagnosis and decisions were based on clinical impression”
3. lack of documented protocols for 24/7 CT scanning
“Reference was made to new protocols about the treatment of patients presenting with similar conditions such as [name redacted] (particularly for 24/7 CT scanning/reporting), but no documents were produced”
4. missed opportunity for earlier surgery
“e Inall likelihood surgery was an earlier possibility for [name redacted]”