SENIOR doctors failed to check a High Bentham pensioner for nearly 24 hours as the man lapsed into a coma and eventually died, an inquest heard.
Hospital staff at Royal Lancaster Infirmary had forgotten to include William Noble’s name to a list of ward checks because they were too busy, a hearing in the city was told.
The hospital has since changed its procedures.
Mr Noble was admitted on November 28, 2008, after complaining of a headache and of feeling generally unwell.
The 83-year-old, who suffered from a heart condition called atrial fibrillation, diabetes, high blood pressure and high cholesterol, was admitted to the Medical Assessment Unit (MAU) of the hospital, and checked by a consultant at 11.15am the same day.
But he was not checked again until 10am the following day. Normally patients would be seen twice a day during ‘post-take ward reviews’ held at 9am and 5pm. By that time, it was too late to perform a CT scan on Mr Noble because he was too ill.
The inquest heard that Mr Noble had also been moved to a ward from the MAU because beds needed to be freed in the unit.
But Mr Gregory Hall, an independent consultant neurosurgeon based in Preston, said Mr Noble would not have undergone surgery even if a CT scan had taken place earlier, because of the risks to an elderly person with his meidcal conditions.
Mr Noble died on November 30 2008 of an acute subdural haemorrhage due to warferin toxicity.
Warferin was the drug he took to keep his atrial fibrillation condition in check.
Recording a narrative verdict, the deputy coroner for Preston and West Lancashire, Simon Jones, said: “It’s unlikely that the outcome would have been altered had he had the CT scan.”
Dr David Fyfe, consultant in medical encology at RLI, said new procedures included a photocopy of the post-take ward check being kept so that an audit trail could track down whether a patient had been seen.
An extra consultant has also been appointed to deal with the workload.
Speaking after the inquest, Mr Noble’s daughter Jill said: “It was a very thorough inquest. I’m just happy that it’s been looked into.
“The outcome wouldn’t have been any different so that is comfort to me.”
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