A 90-year-old man with Parkinson's and dementia died two days after being discharged from hospital after doctors failed to identify he had broken his neck, an inquest has heard.
Peter Dawson's wife had passed away from Parkinson's disease in March 2017, and he had been living at Brundall Care Home when he had a fall on September 3, hitting his head.
He was taken to the Norfolk and Norwich University Hospital (NNUH) and given a CT scan which showed no damage to the skull or brain. But doctors failed to pick up a fracture to his second vertebrae, which had caused a haematoma in his throat.
Despite Mr Dawson's son, Ivan, insisting his father was 'complaining of neck pain and breathing problems', he was discharged the next day.
Norfolk Coroner's Court heard from Heinrich Hollis, clinical governance lead and consultant in emergency medicine at NNUH, who reviewed Mr Dawson's case.
'The most obvious concern is there was a spine fracture which contributed to his death,' he said, adding assessments from two doctors and the ambulance crew had not identified it.
He said: 'If three people are saying the same thing I tend to think what they are saying is probably right. The obvious injury being complained about at the time was lacerations to the scalp.'
Mr Dawson was discharged back to Brundall Care Home on September 4 but was returned to A&E by 3.30pm, when the neck fracture was identified.
'Patients with a head injury, were serious problems have been excluded by a head CT scan, are discharged home when they have adult supervision,' said Mark Davies, chief executive of NNUH, in a response to Mr Dawson's son, Ivan.
'It would not be possible, nor would it be appropriate, for every patient with dementia to receive extended scanning to look for any unidentified injuries. This would not be practical or safe.'
When the neck fracture was located, the presence of the haematoma meant treatment was not an option and Mr Dawson was referred to the palliative care team for end of life treatment.
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.
'The syringe driver was not broken. The nursing staff failed to operate it correctly,' said Mr Davies.
'Despite this 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 happens 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.'
In a complaint to NNUH, read to the court, Ivan Dawson said: 'The way my father has been treated has made it even more painful for us. I believe what dad had to go through on his deathbed was unacceptable.
'They did not seem to understand this was a 90 year old man suffering dementia and Parkinson's. I couldn't believe he was going to be sent home in the morning considering he was still complaining of neck pain and breathing problems.'
Mr Dawson told the court as he was driving to the nursing home on September 4 to see his father following the discharge from hospital, he missed a phone call, and by the time he arrived paramedics had been called.
'Within an hour of being discharged he was back at A&E,' he said. 'Blood tests then showed he possibly had a heart attack which caused the fall. I questioned why this had not been spotted the previous evening.
'I dread to think what pain he had really been in when they showed me the scan of dad's spine. The phone call that he had passed away was a blessing considering what he had gone through.'
Assistant coroner Johanna Thompson said Mr Dawson's death, on September 6, 'occurred as a direct result of the fracture to the spine.'
She adjourned the inquest to gather further evidence from Brundall Care Home after fresh concerns were raised by Ivan Dawson.
It will resume at a date to be fixed.
Unnecessary pain
After the hearing Ivan Dawson, Peter's son, said his father went through 'a lot of unnecessary pain'.
'Dad was a devoted husband of nearly 65 years to Brenda and a family man with two sons, grandchildren and great grandchildren,' he said.
'He worked all his life and even did some voluntary work driving for the hospital and when he was not working would always been willing to help anybody.
'He was a very active person - always out and about down the coast walking the dog until dementia took over.
'Mum passed away in March after long illness with Parkinson's and that broke his heart to see her go like that. We knew his wish would be to be with her which we could understand and would be hard on us to see him go to her.
'In some senses you just wish he would have gone to sleep one night and not wake, but unfortunately this did not happen and we feel he had to go through a lot of unnecessary pain.'
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