The inquest into the death of Mr Gordon Ashton concluded on 10th October 2014. Mr Ashton died on 28th May 2014 at Fairfield Hospital, Bury.
The circumstances surrounding his death are extraordinary and very sad. Mr Ashton had been involved in a serious road traffic accident in 1996, resulting in him suffering paraplaegia. After extensive rehabilitation he returned home and remained extremely independent. However, in 2006 he was admitted to a care home for respite and following serious complications with his health, he was then admitted to hospital. Eventually, he was placed in full time residential care. Mr Ashton remained active despite his limitations.
On 31st July 2012 Mr Ashton was receiving personal care when the sling being used to hoist him into bed was discarded and caught the control of his electric wheelchair causing it to move forward at speed. The chair struck his carer and thereafter his bed causing him to fall to the floor. He sustained a blunt trauma to his right shoulder and neck as well as a head injury.
He was immediately transferred to the A&E department at the Royal Blackburn hospital where he was treated by a GP trainee doctor. He was diagnosed as having suffered a musculoskeletal injury, was prescribed Diazepam, referred to physiotherapy and was given advice to consult his GP if necessary.
Unfortunately, the doctor did not direct any tests or investigations such as an x-ray to exclude the possibility of bone injury to the neck and did not consult a senior colleague for further guidance. Further, the doctor did not appreciate the signs and symptoms Mr Ashton was presenting with.
Evidence was heard at the inquest from the A&E Consultant that in his opinion the mistakes made by the trainee GP doctor were down to training issues.
It was further heard that although there was an MRI on site, the facility was only available Monday-Friday during 9-5 and that any out of hours requests for emergency MRIs went directly to the tertiary centre, thus necessitating the transfer of acutely sick patients between centres. This appears to be due to financial constraints and a lack of adequately trained technicians.
Following this admission, Mr Ashton was discharged but remained symptomatic. His GP attended upon him 3 days later and advised that he be referred back to A&E. Mr Ashton was seen by a different Consultant who arranged a CT scan which revealed 2 cervical spine fractures and an incidental finding of a subdural haematoma. Sadly, Mr Ashton rapidly deteriorated and went into respiratory failure, necessitating an admission to ICU. Once his condition was stabilised, he was transferred to the neurological unit with a tracheostomy in situ, where a further c-spine fracture was noted. Surgery was carried out to stabilise the fractures and a surgical tracheostomy was carried out. After a difficult recovery, Mr Ashton was eventually fit for transfer to the spinal rehabilitation unit.
In February 2012, Mr Ashton was moved to another rehabilitation centre and continued to suffer pain in his shoulders and loss of feeling in his fingers. In April 2012, he was diagnosed with pneumonia. This pneumonia was associated with the presence of foreign bodies in the airways, in this case tracheostomy tubes and aspiration.
Sadly, despite treatment, his condition deteriorated and he died.
Having heard submissions on behalf of the family, NHS Trust and care home, the Coroner made a finding that;
the deceased died as a result of an accident, to which a failure to diagnose three cervical spine fractures – when he presented to the Emergency Room on 31st July 2012 – materially contributed.
Evidence heard during the inquest gave the Coroner cause for concern that there was a risk that future deaths would occur unless action is taken. Where this is the case, the Coroner has a duty to report these concerns to the relevant bodies.
The Coroner has therefore written to the Chief Executive of East Lancashire Hospitals NHS Trust and the Department of Health in connection with the issue concerning the training of the trainee GP doctor and the availability of the emergency MRI out of hours.
The Coroner was of the view that transferring patients for MRI when there is a functioning machine available locally puts very sick patients at unnecessary risk, delays diagnosis and treatment. Further, poor training and supervision of trainee doctors puts patients at risk.
In respect of the care home where the accident occurred, the Coroner was satisfied that sufficient steps have already been taken to prevent a reoccurrence. She further noted that the facts will be mentioned in her Report, thus bringing to wider public attention the risks associated with electric wheelchairs.
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