The last days of a 90-year-old with dementia and Parkinson's turned into a 'nightmare' after doctors failed to diagnose his broken neck from an unsupervised fall, an inquest heard.
Three times on September 3 last year Peter Dawson fell while left alone at Brundall Care Home, the Norwich hearing was told.
And three days later he had died from the broken neck sustained in the final fall, triggered by a heart attack.
After the inquest into his death, Mr Dawson's family said he had suffered 'unnecessary pain' after multiple failings in his care.
The inquest was told doctors at the Norfolk and Norwich University Hospital had failed to spot the fracture in Mr Dawson's spine in a CT scan and discharged him back home on September 4, despite the concerns of ambulance staff.
Within an hour his GP recommended he be re-admitted to hospital, when his injuries were properly diagnosed. But nurses on duty failed to operate equipment properly – leaving him with no medication or pain killers during his final hours, Norfolk Coroner's Court heard.
A former warehouseman from Bowthorpe, Mr Dawson had moved into Brundall Care Home in October 2016 with his wife of 64 years, Brenda, who was also suffering from Parkinson's disease.
She died in March last year, six months before her husband.
At the inquest into Mr Dawson's death, assistant coroner Johanna Thompson ruled it accidental.
But his son Ivan, 57, said: 'We know it was an accidental death. But the accident would never have happened in the first place had he been supervised correctly.'
The court heard Mr Dawson had been assessed as a 'low fall risk', and was able to walk around the home while supervised by staff. But on September 3 he was found 'wandering around' the corridors and appeared confused.
A statement from Brundall Care Home, read to the court, added: 'Mr Dawson was assessed as requiring a staff member to supervise him while mobile around the home. There were times when residents were left unattended unless assisted with one-to-one support.
'Updating care plans is an ongoing process which takes time. Updating his care plan would not have prevented Mr Dawson from falling.'
Ms Thompson, summarising the evidence, said: 'Prior to the morning of September 3 no significant health concerns had been raised, however in the early hours of that day Peter suffered an unwitnessed fall in his bedroom. He was not found to have any injuries and was helped back into bed.
'He had a further fall later that morning in the doorway of the bathroom to the lounge. His fall that evening, however, did cause injury and his head was bleeding.
'Although Peter is reported to have complained of neck pain to staff, observations by the ambulance crew, and later hospital doctors did not indicate any spinal damage. The main concern and focus was his head injury.'
Mr Dawson was returned to Brundall Care Home on September 4, when ambulance and care home staff noticed he was having breathing difficulties. He was returned to hospital within an hour.
'He was then found to have a blood clot in his throat,' added Ms Thompson. 'Tests revealed he suffered a heart attack but he could not be given medication due to the blood clot.
'He was then given a CT scan of the neck which revealed a fracture to part of the second vertebrae. Due to the severity of the condition Peter was appropriate for palliative care. His family have raised a number of concerns about the care provided at the hospital and their failures have been recognised by the Trust, with an assurance lessons have been learned. 'Although failures of care were identified and accepted by the Trust there is no evidence to indicate the outcome would be any different had these not occurred.'
After the inquest, Ivan Dawson said: 'There was a lack of staffing and he should not have been left in that lounge on his own - especially having had two falls that day. If there had been an intervention they would not have left him to have the third.
'He was treated as just a number - not as a person. He was 90 years old so he was treated like he had no more life left.
'I am pleased he died because he is in a better place now and he is with my mum. It seems cruel but it comes from the way he was treated in his last days. It was a nightmare.'
'Sincere apologies'
Despite a medication plan in place, Mr Dawson was not given any painkillers as nursing staff failed to put in place protocol, and were unable to operate a syringe driver brought from another department, the court heard.
Mark Davies, chief executive of NNUH, said in a response to Mr Dawson's son: 'There was adequate opportunity for your father to be given medication. Regrettably he was not administered with any of this medication which could have been given by nursing staff on the ward. Despite a lot of education across the Trust regarding ensuring end-of-life patients are as comfortable and pain free as possible, this failed in your father's case.
'This is an issue the ward have taken very seriously to avoid this situation ever happening again.'
Mr Davies has also offered Mr Dawson's family 'sincere apologies' for the care provided.
'It is clear we did not get things right in this case, and your father deserved better care,' he said. 'Though his death could not have been prevented his final hours were not managed well.'
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