Failure to diagnose back injury
A disabled man who broke his back when his wheelchair toppled over died within an hour of being discharged from hospital after a doctor's failure to diagnose the back injury, an inquest heard today.
An independent assessment found that Dr Sanjay Pandanaboyana, the senior house officer at the Royal Glamorgan Hospital in Llantrisant, south Wales, fell below the required standard during his examination of 64-year-old Walter Langford.
Mr Langford, who was a permanent resident at the Cwm Coed Nursing Home in Ystrad Rhondda, south Wales, was being driven to Tesco on December 18 2004, by casual assistant Louise Reed, when his wheelchair fell back.
The inquest at Pontypridd heard that Ms Reed had not strapped the wheelchair into the van properly.
Ms Reed admitted: "I'd had no professional training to secure the wheelchair in."
She added: "I was approaching the traffic lights when I heard a bump. I turned around and saw that Walter's wheelchair had toppled over."
Ms Reed drove Mr Langford to the Royal Glamorgan Hospital where he was examined by triage nurse Delyth Evans who found his blood pressure, heart rate and oxygen saturation levels were all low.
As Mr Langford had learning difficulties and could not communicate properly, he was unable to tell staff of his pain.
X-rays were taken of Mr Langford's neck and head - where he had sustained a graze - but not on the thoracic part of his spine where he had suffered a serious fracture.
Mr Langford was subsequently sent away from the hospital, but Ms Reed noticed his head had bowed barely 20 minutes into the journey back to the nursing home.
She attempted resuscitation and flagged down another motorist who rang emergency services.
Mr Langford was taken by ambulance back to the Royal Glamorgan Hospital where he was pronounced dead.
Dr Rupert Evans, a consultant in emergency medicine at the University Hospital of Wales, Cardiff, was commissioned to look into the circumstances of Mr Langford's treatment.
Failure to diagnose back injury 'not grossly negligent'
He concluded that Dr Pandanaboyana was not grossly negligent for the failure to diagnose back injury, but should have tried to find out why Mr Langford's blood pressure, heart rate and oxygen saturation levels were abnormal.
Dr Evans said the fracture suffered by Mr Langford was most unusual and that he'd only seen a "handful" in 25 years of practice.
He added: "It is my opinion that even if I was looking after him (Mr Langford), he still would have died on the balance of probabilities.
"It is a dire injury and carries significant mortality rates."
Detective Constable Jeff Davies of South Wales Police told the inquest that an extensive investigation was carried out which found the nursing home and Dr Pandanaboyana had been negligent.
Mr Davies said the Crown Prosecution Service subsequently decided there was no criminal case to answer.
Home Office pathologist Dr Andrew Davidson found Mr Langford died as a result of severe compression of the spinal cord as a result of the fracture.
Pontypridd coroner Philip Walters said he did not blame Ms Reed for failing to strap Mr Langford into the van properly because of her lack of training in the procedure.
He added: "The clinical examination by the senior house officer has fallen short of what is required.
"This is the sort of back injury that a junior doctor may not have seen.
"I think the key in the doctor's statement (Dr Evans) is that when the parameters carried out by the nurse were presented to the doctor (Dr Pandanaboyana) then he should have been put on notice that there was something wrong and there were underlying problems.
"It was not the right thing to release Mr Langford into the community although there is every probability that he would not have survived."
A verdict of accidental death was recorded.
After the inquest, Mr Langford's brother, Merlin, said: "All I hope is that it doesn't happen to anybody else.
"He was severely handicapped and I'm not blaming anybody else but I think the hospital could have done more."
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