Coroner's concerns over hospital brain scan delay

Raymond Leake hit his head after falling on a ward at Hull Royal Infirmary

A coroner has raised concerns after the death of a man whose brain scan was delayed.

Raymond Leake, 83, fell over on a ward and hit his head at Hull Royal Infirmary in February. A CT scan did not take place until 14 hours later, Hull Coroner's Court heard. It revealed Mr Leake had an unsurvivable catastrophic bleed on his brain, and he died three days later.

Coroner Lorraine Harris said that "had the bleed been identified earlier the outcome would not have changed" as his other medical problems "would have prevented him from [having] surgery", but it would have allowed his family to spend time with him while he was still conscious.

The NHS said it acknowledged the concerns raised in the report.

In her Prevention of Future Deaths report, Ms Harris raised issues with communication between hospital departments and the possible impact of staff shortages.

She also highlighted a "lack of communication with the family" following Mr Leake's injury.

Ms Harris said that there were only two registered nurses on the ward when there should have been three.

"It would be unsafe to assume exactly whether the appropriate staff number on duty would have prevented the fall, but... there was inadequate staffing on the evening of the incident," she wrote.

She said a nurse correctly followed protocol and requested an urgent scan "but for reasons unknown the radiology department did not book Mr Leake to attend for a CT scan. It was heard in evidence this was likely due to human error".

The inquest heard that the CT department called the ward four times the following morning, but there was no answer.

Eventually he was taken for a scan by the hospital's Falls Team at 10:45 GMT the day after his injury.

"This is 13 hours and 33 minutes after the incident, over 5 ½ hours after the optimum recommended time," the coroner wrote.

In her letter to NHS Humber and North Yorkshire Integrated Care Board (ICB), Ms Harris wrote that despite efforts to find out why the scan was missed, "no exact reason was found".

She added that a review of the radiology department's working practices "was still not completed by the time Mr Leake's death came to inquest".

"This meant that I could have no reassurance that these processes are working appropriately or that further urgent scans would not be missed in future," she wrote.

Michelle Carrington, acting executive director of nursing and quality at the ICB, said: "We acknowledge the concerns raised in the coroner's report and extend our deepest sympathies to Mr Leake's family.

"The ICB is reviewing the findings in detail and working with system partners to ensure that appropriate actions are taken to address the issues identified and prevent future harm."

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