Hospital transfers and lack of collars did not contribute to death, inquest finds

Hospital transfers and confusion over spinal protection collars did not contribute to the death of a 78-year-old woman, an inquest was told today.

Margaret Richardson, of Maltby, Rotherham, died at the Northern General Hospital on 27 May 2017 after undergoing two surgeries between Rotherham General Hospital and Sheffield’s Hallamshire Hospital and underwent two surgeries during the course of her hospitalisation.

The Rotherham Hospital found that spinal disk damage was the cause of Mrs Richardson’s weakness in mobility, the inquest at Sheffield coroner’s court heard.

Mrs Richardson’s son, Ian Richardson, said after his mother’s first surgery: “It was just a joy to see her. She was hitting my hand with her leg.

“She never became as well after the second as the first.”

Dr Jon Miles, Director of Clinical Services at the hospital, said complications arose after the second surgery when a drain was “inadvertently pulled off, presumably by Margaret [Richardson]” and she developed bleeding in the spinal canal.

The inquest heard that Mrs Richardson experienced bleeding, chest and urinary tract infections after the second surgery and her condition progressively deteriorated until her death.

Dr Kitsanta said Mrs Richardson’s complications “stressed her out and to an extent that may have been a high risk factor.”

However, Mr Richardson said there was confusion among staff members about collars that Mrs Richardson was required to wear to avoid pressure on her spine.

He said medical reports indicated that the collars were required but staff were not aware of the need.

He said: “I think a lot of that was because my mum was displaced.

“If they were aware of how ill she was, that makes it worse for me. Why on earth did they decide to move her there?”

Dr Miles said the confusion was in part because of confidence issues, and added: “In general, people try as hard as they possibly can to put people in the right place.”

He said that repatriation of patients suffering from spinal diseases required a more vigorous procedure.

The transfer of Mrs Richardson between wards and hospitals was also, he said, “a poor quality of care event to have happened” on the part of their organisation.

He said, to decrease the number of ward moves, their team is increasing the number of beds in wards and putting specialists in to assess conditions in good time.

He added: “We hope this will lead to timely discharges and reduced risk of hospital-induced infections.

“For the future Margarets, we need to put in other systems.

“This is as robust a response as we can put in to prevent them [complications] from happening again.”

Mr Richardson also requested better communication between hospital staff and patients’ families.

Assistant Coroner Katy Dickinson said the transfers and confusion over collars “did not contribute to Mrs Richardson’s death.”

She recorded a verdict of death with the medical causes of acute myocardial infarction and pneumonia and coronary atherosclerosis and spinal surgery.