March woman died after catalogue of failings

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A March woman died following a catalogue of failings by emergency services, an inquest has heard.

Vivienne Morton died of a head injury less than two days after being discharged from Peterborough City Hospital and at Wednesday’s hearing in Wisbech, her family questioned whether she received the correct treatment.

The 57-year-old fell and hit her head near her home in The Avenue on May 8, 2012, leaving her unconscious for several minutes, and had to wait over an hour for an ambulance to take her to hospital.

Once at hospital staff failed to realise the seriousness of Miss Morton’s condition and did not undertake the correct neurological observations normally given to a patient with a head injury, despite her son raising concerns.

She was discharged from hospital without undergoing a CT scan for her injury, but within hours her son was dialling 999 for an ambulance, which again was delayed in arriving, because she had started vomiting and was becoming unresponsive.

She was taken back to Peterborough City Hospital where she underwent a CT scan more than three hours after being readmitted. This showed a massive bleed in her brain and she was transferred to Addenbrookes’ Hospital in Cambridge, where the family were told she could not survive.

The inquest heard she died less than a day later and two days after sustaining the injury.

A regional manager for the East of England Ambulance Service apologised for the delays in getting to Miss Morton and said they have now made changes to the way they operate to minimise future problems, including employing more front line staff.

Coroner William Morris said he was left “concerned” after hearing about the failings which he implied may have contributed to Miss Morton’s death.

Miss Morton had a history of alcohol problems and was suffering from alcoholic cirrhosis.

Her sister, Judith Morton, quizzed consultant Lieutenant Colonel Lorraine Greasley about her sister’s care at the Peterborough hospital and she admitted Miss Morton should have received a CT scan on her first admission.

Judith Morton said: “I feel my sister was treated for a minor fall as an alcoholic, not as someone with a serious head injury.

“She was denied any intervention that could have given her a meaningful opportunity for recovery.”

The inquest heard Miss Morton was returning home when she appeared to lose her balance and fall over. Neighbour Richard Baxter described how she was “unsteady” on her feet and then spun around, falling and hitting her head on the kerb.

He went to her aid, flagging down a passing nurse who called 999 and a Community First Responder was with them within three minutes. However, an ambulance took over an hour to arrive.

Nicholas Jones, EEAST regional manager, put the delay down to high demand and delays in handovers at other hospitals which had put pressure on resources. Poor weather was also a factor on that particular day, with flooding in some areas.

Later that evening, after her discharge, Miss Morton’s condition deteriorated and an ambulance was called again, and again it took almost an hour and a half to arrive due to flooding on the roads.

When making his narrative verdict, Mr Morris said there were matters he had heard that “caused me some concern”. He included the one hour and three minutes delay in the ambulance arriving and the fact Miss Morton was discharged from Peterborough City Hospital without having a CT scan. He expressed his sincere condolences to Miss Morton’s family.