Woman died after staff failed to note X-ray result

Margaret Pilgrim died at the Princess Alexandra Hospital 26 days after she was initially discharged from it

An 88-year-old woman who fractured her collarbone was discharged from hospital without painkillers before her death, a report revealed.

X-ray scans at the Princess Alexandra Hospital, in Harlow, Essex, uncovered Margaret Pilgrim's injury but staff did not note it down, a prevention of future deaths report said.

Ms Pilgrim, who had been hurt during a fall at home, was released from the facility but died on 29 June 2023 after her condition "declined rapidly".

The Princess Alexandra Hospital NHS Trust said it was "committed to learning" from the incident and making improvements.

In her report, Sonia Hayes, the area coroner for Essex, said Ms Pilgrim had been discharged "with no pain relief or consideration of care package".

Her cause of death was recorded as congestive cardiac failure and bronchopneumonia, with her fractured clavicle also a contributing factor.

Finola Devaney, a senior staffer at the hospital trust, apologised for the gaps in Ms Pilgrim's care

Ms Pilgrim was initially taken to the Princess Alexandra Hospital after she suffered an unwitnessed fall at home on 3 June 2023.

She received an X-ray scan, which picked up the fractured clavicle, but "this was not noted, and Mrs Pilgrim was discharged", Ms Hayes wrote in her report.

The 88-year-old was prescribed a painkiller by her GP on 6 June that year but her condition rapidly deteriorated.

Ms Pilgrim was admitted back into hospital on 19 June where she continued to decline and died ten days later.

The coroner said the patient did not receive the necessary support from the hospital's fracture clinic due to the omission of her injury on a discharge summary.

Her fracture was only confirmed when the GP raised the family's concerns with the hospital trust.

'Committed to learning'

Ms Hayes said the trust must provide to her in writing what action it proposed to take by 5 August.

Finola Devaney, the director of clinical quality and governance at the hospital trust, said staff wanted to offer their "deepest condolences" to Ms Pilgrim's family.

"We apologise for any gaps in her care and treatment, which impacted on her subsequent care," she said.

“We are committed to learning from this incident and ensuring that improvements are implemented."

Ms Devaney said a full response would be issued to the coroner by the August deadline.