West Suffolk Hospital is being told to tell doctors to give full information on why X-rays are needed after an elderly woman was refused one that might have revealed a fracture.
Suffolk Corner Dr Peter Dean told the inquest on Else Harvey-Samuel, 89, of The Martins home in Linnet Close, Bury St Edmunds, that he would also suggest they tighten up incident investigations.
Simon Manning, from The Martins, said she had a fall on February 14, 2013, and though she could move her legs complained of pain in her groin. Her GP felt she should have X-rays the next day, but by 10.30pm her condition had worsened so she was taken to West Suffolk Hospital by ambulance.
Dr Mohonraj Suresh, a consultant geriatrician, said fractures are not always visible on the first X-rays, but a few days later the damaged bones have opened up, making the visible.”
He said because of the drugs and her dementia Mrs Harvey-Samuel was unable to pinpoint where her pain was, but she had bruising on her groin, so on February 21 he asked for X-rays of her pelvis, hip and knee.
Dr Vinod Shenoy, consultant radiologist on call on the 21st, said he had a five minute phone conversation with the radiographer who was concerned about X-raying the hip and pelvis of someone doctors said had knee pain. He felt she was right to refuse the extra X-ray exposure. He said he had no discussion with any doctor.
Dr Karl Love, pathologist, said Mrs Harvey-Samuel had a haemorrhage around a pelvic fracture in the pubic area and bone marrow and fat embolism associated with it. There was also evidence of a recent heart attack, coronary disease and pneumonia.
Dr James Barrett, a consultant radiologist who compiled a report on the case after her death on February 24, said the records showed the request for X-rays only referred to knee pain, so did not justify the radiation exposure from imaging other areas.
Dr Dean queried the adequacy of the report.
Dr Barrett said: “Never having had any formal training in the investigation system itself, I investigated it as I saw fit at the time.”
Summing up, Dr Dean said it was likely the pelvic X-ray would not have altered the outcome, but it would have enabled staff to better target pain relief.
His conclusion was that she died of complications following a fall and pelvic fracture which were contributed to by existing natural diseases.
He said he would write to the hospital to say requests from doctors for any imaging should give ‘sufficient clinical information to explain why the investigation is justified’.
He said he would call for discussions between consultants to be documented and where an incident needs to be investigated a system for determining the level should be ‘sufficiently robust’.
A spokesman for West Suffolk Hospital said: “We will act on the coroner’s recommendations when we receive them.”