A grieving daughter has told an inquest that her mother fell into a "black hole" of care failings after suffering a serious stroke.
The inquest at Cannock heard of a catalogue of problems in the care of 82-year-old Audrey Wakefield, from Stone, after she first suffered a stroke in January last year, including NHS IT systems that could not communicate with each other, lack of coordination between hospital and community health care, a fall at a residential home, followed by a visit to A&E which appeared not to have discovered a spine fracture and head injury.
Mrs Wakefield’s daughter, Anne Dicks said she wanted lessons to be learned from her mother’s death, and said she feared that the whole Stone area remained in the same ‘black hole’ because care was not joined up between different health providers.
“If this inquest on mum can help that change it will be a good outcome,” Mrs Dicks said. “I wouldn’t be putting myself through all this hell otherwise.”
The inquest was adjourned to a date to be fixed because one of the witnesses, Dr Firasai Khan, who was a locum A&E doctor at Stafford Hospital during Mrs Wakefield’s illness, failed to appear due to a mix-up over dates. South Staffordshire coroner Andrew Haigh said he was an ‘important’ witness.
The inquest heard that Mrs Wakefield, of St Michael’s Mount, Stone, a former schoolteacher, and a volunteer helper at Stone Stroke Club, suffered a severe stroke, caused by a blood clot, on January 8, 2013.
She was taken to the University Hospital of North Staffordshire’s stroke unit, and consultant Dr Indira Natrajan said she made a good initial recovery, though she had speech and mobility problems. Mrs Wakefield also suffered from atrial fibrilation - an irregular heartbeat - which meant a tendency to bloodclots, so it was decided she should start on warfarin treatment to thin her blood.
She was discharged home on January 1l, and Dr Natrajan said he telephoned her GP at Stone’s Cumberland House Surgery to inform him.
But it later transpired that the electronic discharge summary sent by UHNS was not received by the surgery because it did not have the same Medisec computer system.
UNHS also had to refer Mrs Wakefield to the central Staffordshire community stroke team, rather than its own North Staffordshire team for follow-up therapy, but it appeared that the referral for community care was not picked up.
The inquest heard that Mrs Wakefield was referred by a social worker for respite care at Manor House care home, in Walton, Stone, because she was not coping at home.
While there she fell backwards against a cabinet while trying to get out of her chair.
The current manager of the home, Lesley Powell, who was not working there at the time of the fall, on February 21, said it appeared from the records that a mobility risk assessment had not been carried out on Mrs Wakefield.
Care staff called out paramedics and she was taken to Stafford Hospital, but was returned early the next morning, and staff were told there was no bone injury and no treatment had been given. But no discharge records were sent with her, Mrs Powell said.
She added that a local GP was called the next day, but told staff no visit was necessary as Mrs Wakefield had been seen by a hospital doctor.
Mrs Wakefield’s condition deteriorated and she was taken to UHNS on February 24. A CT scan on February 26 discovered a traumatic bleed on her brain. Dr Natrajan told the inquest this was a risk with blood-thinning treatment.
Further scans revealed more blood clots around her body, but she failed to respond to treatment, and she was transferred to Douglas Macmillan Hospice in early April and died there on April 11.
Pathologist Dr Terence Hollingworth told the inquest that Mrs Wakefield had fractured a vertebra in her spine in the fall, and had also struck the back of her head, which he said had damaged the internal connections in her brain and caused the bleed.
“I am definitely of the opinion that it was traumatic and there was no other reason for the bleeding,” he said, adding that even minor head injuries were ‘important’ for patients on warfarin.
The immediate cause of death was pneumonia, and Mrs Wakesfield had also suffered a closed head injury, a stroke and atrial fibrillation.