Care review at Telford hospital after grandmother's death

Coroner Mr John Ellery criticised the "suboptimal" care given to Cynthia Lancaster at the Princess Royal Hospital, Telford, in September last year.

Mr Ellery said lessons should be learned following Mrs Lancaster's death.

The inquest was told the care Mrs Lancaster received was not "optimal" and "probably" contributed to her death.

It is the latest case that has sparked a review of procedures at the Princess Royal Hospital and the Royal Shrewsbury Hospital. The 80-year-old grandmother, of Newport, died due to a small bowel obstruction, the inquest held at Shirehall in Shrewsbury heard.

However, Mrs Lancaster was diagnosed and treated for constipation and acute kidney injury, despite an X-ray being carried out.

The inquest heard that trainee doctor Ioannis Leontsinis conducted the X-ray and consulted with Dr Abhijoy Chakrabarty, the on-call surgical registrar, over the phone.

Mr Ellery, coroner for Shropshire, Telford and Wrekin, said the trainee doctor suggested there could have been a blockage to the small bowel but was taken "off course" by Dr Chakrabarty.

The coroner said those on-call could not make a judgement without seeing the X-ray for themselves, an issue he said that he had come across at a previous hearing.

The inquest also heard that nurses, who were working on the ward at the time, failed to call for a medical review into Mrs Lancaster when a system used to detect a patient's condition rose to a concerning level overnight.

It was the following afternoon that Mrs Lancaster become critical and entered cardiac arrest after deteriorating rapidly throughout the morning.

She died on September 12 last year.

Mr Ellery, who recorded a narrative conclusion, said Mrs Lancaster "did receive basic medical attention", but found the care was "suboptimal".

He said: "The deceased died from small intestinal obstruction, she did not receive optimal care and that in part contributed to her death. I am not going to identify any individual. It is the accumulation of how Mrs Lancaster was treated."

He added that despite the misdiagnosis, and even if the small bowel obstruction had been identified, the "overwhelming evidence was that she was not fit for surgery".