An elderly Swindon man died after suffering a fatal injury in a fall at his home a coroner has ruled, after a two-year wait for an inquest.
Norman Woodason hit the back of his head after losing his balance while walking up stone steps at the front of his Blunsdon address at 8.30am on October 1, 2022.
Paramedics eventually took the 88-year-old to Great Western Hospital, though pressures on the ambulance service and the low priority of the callout meant that they did not get to his home until 7.15pm.
Senior coroner for Swindon and Wiltshire David Ridley explained at an inquest in Salisbury’s Coroners Court on Wednesday morning that although Mr Woodason had mentioned “the worst headache ever” during the journey to hospital, it did not get mentioned when he was examined at GWH.
So, he did not meet the criteria set out in the NICE guidelines for a CT scan to be carried out and instead received X-rays for his elbow and humerus before being sent home with morphine to ease the pain.
Evidence from a doctor read out at the inquest said that “everything seemed normal”, “he had had a headache but this had settled” and there was “no neck pain or stiffness, so no further enquiries were undertaken”.
Mr Woodason decided to go back to the hospital voluntarily on October 4 because he had struggled to get out of bed and worried about pain in his back.
Doctors saw no cause for alarm as his vision was fine and he had not suffered any loss of consciousness or other symptoms, so he was discharged again.
Only during the third hospital visit, on October 7, did he start presenting with symptoms of a worsening headache and general confusion that necessitated a CT scan.
This revealed a traumatic subdural haemorrhage inflicted by his fall a week earlier.
The patient was taken to a ward and a second CAT scan was scheduled for two weeks, then brought forward more urgently after his condition deteriorated on October 18 and he was transferred to another unit from intensive care.
Sadly, doctors determined that the injury had worsened to an inoperable extent and placed the patient on end-of-life care until he passed away on October 22.
Before concluding the inquest, Mr Ridley apologised to the family for the unusually long time it had taken to get to the end of this process.
He said: “I regret that it’s taken nearly two years to reach the final hearing.
“We were in a situation where we had lost 50 per cent of our coroner’s officers and support team. Even during 2022 and 2023, I was doubling up as a coroner’s officer.
“We are struggling to get out of that, we are getting support in terms of replacements but two of those did not work out so they have been replaced and we are training two new members of the team.
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“Hopefully by next year, with support from the local authority and Swindon Borough Council, we will recruit a second full-time area coroner which will improve matters.
“This is not our normal standard but the vast majority of families have been fairly understanding of the challenging situation we have faced during the last two years and the pandemic.
“It is not out of choice that we delay hearings, it’s due to the complexity of the work.”
Mr Woodason was born in London and worked as an importer and exporter before retiring.
Mr Ridley recorded the cause of death as an accident due to traumatic subdural haemorrhage and fall, then passed on his condolences to Mr Woodason’s widow and son.
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