Kettering General Hospital admits errors and apologises after failing to spot elderly woman's broken spine

The acute hospital says it ‘deeply regrets’ failing to spot Mrs Webster’s broken neck when she was admitted to them from Thorndale Care Home in Malham Drive, Kettering, in November 2017. They transferred her for needed facial treatment at Northampton General Hospital while sending over the wrong scans – meaning the spine injury was unknown.

A Safeguarding Adult Review published today (Tuesday) by the Northamptonshire Adult Safeguarding Board (NSAB) has issued a number of actions and recommendations for the agencies involved in the care of Mrs Webster, who died at KGH on November 28, 2017.

Mrs Webster, who had fallen eleven times in 2017 – seven of them between October and November – was taken to Kettering General Hospital on the evening of November 10 by paramedics after falling in the care home and injuring her back.

She was discharged at lunchtime the next day after a back assessment and head scan but within hours had fallen again, cutting her face on her glasses and was re-admitted to KGH.

After doing a scan on her back and head KGH transferred Leeds-born Mrs Webster to NGH as the hospital was the specialist in treating facial injuries.

However KGH did not send over the correct scans, instead sending over those that had been taken the day before. KGH staff also did not check the scans before sending her to the neighbouring hospital and did not pick up her broken spine.

Mrs Webster was treated at NGH for her facial injury and sent back to the home on November 13.

The report says: “KGH’s acknowledged error in relation to viewing the three scans on Mrs Webster’s return to hospital on November 11 and transferring the correct scans to NGH that evening, meant that Mrs Webster was moved without a fully informed risk assessment, and subsequently NGH made decisions about treatment and transport back to Thorndale without crucial information.”

But after being unable to take her medication and being in pain staff contacted her GP, who spotted the spine break when looking at the scans.

After being re-admitted to KGH the 86-year-old’s health deteriorated, with palliative care being agreed on November 23 and the widower died at the hospital on November 28. A post-mortem examination found her death was from natural causes as result of bronchopneumonia, likely exacerbated by lack of mobility due to the neck collar worn.

The month after her death a social worker referred Mrs Webster’s death for a Safeguarding Adult Review and the NSAB decided in February 2018 to carry one out.

The review – which was written by Shirley Williams – has also highlighted some issues within adult social services.

The report found there had only been one contact from a social worker in the two years Mrs Webster was a resident. The pensioner also did not receive an annual care review and the contract arrangement meant adult social services did not monitor the home, instead allowing Shaw Healthcare to self-monitor.

Mrs Webster first moved into the home in September 2015 and her family said she was happy for the first year. However they themselves raised concerns in the summer of 2017 after a change of staff at the home, and they thought standards had slipped. On one occasion Mrs Webster’s daughter helped out because of staff shortages.

The report said it is possible to speculate that Thorndale staff and health staff regarded her falling as ‘normal’ for her but not dangerous, and developed a level of tolerance.

It said the home had not made any safeguarding referrals about Mrs Webster.

It said: “During the period 1st January 2017 to 10th November 2017, there were no referrals to the NCC Safeguarding Team in relation to Mrs Webster from any organisation. Thorndale report that she had 34 falls during that period; 5 required an A&E hospital visit, but only 2 during 10- 12th November required an overnight hospital stay. None of the falls up to 10th November led to a safeguarding referral.”

The role of the review is not to apportion blame, instead it looks at the actions of agencies involved and makes recommendations to prevent a similar instance happening again.

It said: “Given her increasing number of falls and frequency of ill health incidents, research informs us that it was statistically predictable that Mrs Webster would die following a fall.”

There are a number of recommendations for all agencies involved with KGH’s own internal recommendations that it develops an emergency transfer document. The review recommends that adult social services should monitor all provider contracts evenly regardless of the type of contract and should provide assurance to the board that current actions to enhance its care review team are having a positive impact.

In an issued statement chairman of the Northamptonshire Adult Safeguarding Board Tim Bishop said: “A number of recommendations have been identified as a result of the review. This includes requiring Kettering General Hospital to provide assurance that a clear action plan is in place and being implemented to prevent similar errors happening again.

“The recommendations also seek to make sure that plans are in place to ensure people are receiving appropriate support and that risks to safety are assessed and managed. This includes ensuring that when staff in care homes have concerns about being able to meet all of the needs of a resident appropriately, they refer them for an urgent care review.

“Action plans have been developed by the relevant services and Northamptonshire Safeguarding Adults Board will continue to review and monitor the plans to ensure the agreed actions are implemented in a timely manner.

“Family members were involved in the review and provided valuable insight for the Safeguarding Adult Review Panel, and the board would like to thank them for their input with this SAR.”

KGH’s director of nursing Leanne Hackshall said: “We would like to apologise to Mrs Webster’s family for aspects of her care including our failure to diagnose a spinal fracture and to pass on the most recent CT scans to Northampton General Hospital.

“Mrs Webster was brought to our A&E department twice on November 10to 11, 2017, after having two falls at her care home.

“On the first occasion a CT scan of the head was clear and she was discharged. On the second occasion a CT scan – which included the cervical spine – was taken which revealed a fracture.

“Regrettably the first scan was sent with her to Northampton General Hospital and not the most recent one.

“We carried out a serious incident review into this and have also fully participated in the adult safeguarding review of the entire circumstances leading up to her death.

“While the review found that – given Mrs Webster’s advanced age and many medical problems including severe osteoporosis – that her treatment would have been unaffected by this error, we do deeply regret that it occurred.

“Since the incident we have revised our processes to address the issues raised in the review.

“This includes a transfer document which means that all the most recent interventions and scans need to be listed and highlighted when we transfer a patient to another hospital.

“We have also reviewed our safeguarding procedures in A&E focusing on adult safeguarding and the identification of vulnerable patients.”

Northamptonshire County Council has been contacted for a response.