Woman died because hospital staff did not follow protocol, inquest hears

Doctors at the Royal Oldham Hospital missed the opportunity to consider treatment for a woman who later died because staff did not follow protocol, an inquest heard.

Ann Taylor, 53, who had severe learning difficulties and a number of long-term health problems, had a CT scan at the hospital on 7 February after being admitted six days earlier with respiratory problems.

The findings of that scan were sent to Dr Joshi, a specialist radiologist at North Manchester General Hospital, who ruled that a large blood clot may have been blocking two arteries, Heywood Coroner’s Court was told this week.

Dr Joshi faxed over the results to the Royal Oldham and advised an urgent clinical evaluation.

However, staff at Oldham had no record of receiving the information and Dr Joshi did not speak to anyone at the hospital directly — against Pennine Acute Trust protocol.

Miss Taylor was discharged on 11 February without anyone at the Royal Oldham Hospital seeing the scan results — even though they were marked “urgent”.

Only five days later Miss Taylor was rushed back to the Royal Oldham Hospital after being found unresponsive by staff at the nursing home she lived in and later died.

A post-mortem conducted by pathologist Dr Alan Padwell revealed Miss Taylor had died from a large blood clot which completely blocked one of two arteries with the other being completely clear — contradicting the scan.

Doctors at the Royal Oldham only found the scan results when Miss Taylor was admitted on the 15 February but said they would not have treated her any differently had they known earlier.

Following Miss Taylor’s death, an internal investigation was carried out by the Royal Oldham Hospital.