Margaret Ellen Smith waited two days for X-ray then died

Date published: 14 July 2017


Margaret Ellen Smith waited two days for an X-ray on her chest before she died, an inquest heard.

Margaret Ellen Smith, 78, died the day after the procedure on March 27, 2016, an inquest at Heywood Phoenix Centre heard.

She was originally admitted to the Royal Oldham Hospital in February, 2016, following a fall and was discharged on 4 March - during her time there she had thrombosis pain in her leg, had vomited blood, which tests could not explain, and developed diarrhoea.

Mrs Smith, who was diagnosed with diabetes around 20 years prior to her death, was re-admitted to hospital on 10 March 10 after she took an afternoon nap and her son, Ronald, who was caring for her found her unresponsive.

While in hospital she was diagnosed with C. diff, a bowel infection, and developed a chesty cough - when she developed the cough, an X-ray was ordered on 24 March, however it did not take place until the night of 26 March, the inquest heard.

Pathologist Dr Alan Padwell said that while carrying out the post mortem he found that Mrs Smith had a 'grossly' enlarged heart, which was an indication of severe strain over several years, her lungs were 'waterlogged', she had kidney disease and cirrhosis of the liver.

He found no C. diff infection and said that this would mean it had been treated by doctors.

Family members raised concerns about the level of care she received, saying that their concerns about her ability to cope at home when she was being discharged on the first occasion were ignored.

They also had concerns about the monitoring of her diabetes whilst in hospital, believing that it had not been checked properly and also questioning why when an X-ray was ordered it took two days for it to occur and why little action had been taken on previous X-rays.

Speaking at the inquest, doctors said there had been care given to Mrs Smith but admitted the documentation of this could have been better.

With regards to action taken after X-rays they said that they must be cautious when treating someone with C. diff as antibiotics can have an adverse effect on it. Dr Alan Padwell advised that the cause of death should be pneumonia with several contributing factors.

He said: "I think that the final cause of death I am quite sure is bronchial pneumonia.

"The question is why did she get it?

"All the things that she has got and the situation she is in.

"An ill patient in bed is at risk of getting other infections and all these other things contribute to her in getting pneumonia."

The inquest has been adjourned.

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