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Stone pensioner's inquest: coroner calls for hospital improvements

By Staffordshire Newsletter  |  Posted: April 10, 2014

Stone pensioner Audrey Wakefield's inquest: coroner calls for hospital improvements

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A CORONER has called for improvements in the way local hospitals communicate with GPs after the death of Stone pensioner Audrey Wakefield.

An inquest heard claims from Mrs Wakefield’s family that the 82-year-old, of St Michael’s Mount, fell into a “black hole” of care failings and lack of communication between healthcare organisations after she suffered a stroke.

South Staffordshire coroner Andrew Haigh said he would be contacting the University Hospital of North Staffordshire to raise concerns about how it communicated with GP practices around the area when it discharged patients from hospital.

“I am satisfied there was no gross failure in respect of her death, but I do find that a number of concerns expressed by family members do appear to be justified,” South Staffordshire coroner Andrew Haigh said.

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The inquest at Cannock heard of a catalogue of problems in the care of Mrs Wakefield, a former teacher and treasurer of Stone Stroke Club after she first suffered a stroke in January last year.

These included NHS IT systems that could not communicate with each other, lack of coordination between hospital and community health care, and a fall at a residential home, followed by a visit to Stafford Hospital A&E, where staff did not discover a spine fracture and head injury.

The inquest heard that Mrs Wakefield was treated at UHNS for a severe stroke last January, but when she was discharged home the electronic discharge summary sent by UHNS was not received by her GP at Stone’s Cumberland House Surgery, because it did not have the same Medisec computer system.

UHNS 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.

“Particularly with a view to the fact that UHNS will be taking over Stafford Hospital I do want to check that the conveyance of appropriate information on patient discharge is going to be effective for all GP practices in the geographical area,” Mr Haigh said.

“Conveyance of information should tie in with the expansion of the North Staffordshire hospital’s main area.”

He added that there seemed to have been “minimal” contact with Mrs Wakefield by community stroke care services. There were also “concerns” about the events at Stafford Hospital, but they were not sufficient for the coroner to make a report about them, he said.

The inquest was told that few days after Mrs Wakefield came out of hospital she moved to Manor House care home, in Walton, Stone, because she was not coping at home. But while staying there she fell backwards against a cabinet while trying to get out of her chair and was taken to Stafford Hospital.

Locum A&E consultant Dr Firasai Khan told the inquest that she seemed mentally alert and there was no evidence of head injury, though she was complaining of lower back pain. But an X-ray found no damage to her lower back or pelvis. An upper spine X ray or CT scan were not warranted by her symptoms, he said.

She was discharged with “verbal instructions” to her family about her care. Dr Khan said that as a locum he was not familiar with Mid Staffs Health Trust’s systems, but discharge notes were generally sent by post a few days later.

Mrs Wakefield’s condition deteriorated over the next couple of days and she was taken to UHNS on February 24. A CT scan on February 26 discovered a traumatic bleed on her brain. She failed to respond to treatment and died in Douglas Macmillan Hospice on April 11 last year

Pathologist Dr Terence Hollingworth found that Mrs Wakefield had fractured a vertebra in her upper spine in the care home 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.

The immediate cause of death was pneumonia, and Mrs Wakefield had also suffered a closed head injury, a stroke and atrial fibrillation.

Mr Haigh concluded that Mrs Wakefield’s death was accidental. He said the stroke was a “naturally occurring event”, but the brain injury was caused by the fall at the care home.

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