Telford pensioner died after suffering cardiac arrest as she was discharged from hospital

Eileen Davies, 81, died after suffering a cardiac arrest as she was being transported from Telford's Princess Royal Hospital to an ambulance.

After collapsing, Mrs Davies was taken from the ambulance back to ward 10 from where she had just been discharged, yesterday's hearing was told.

Shropshire coroner Mr John Ellery concluded Mrs Davies had died on January 29 as the result of an accident.

He had adjourned the hearing in May to try and find out why she was not taken to the closer accident and emergency department, and Mrs Davies's family also wanted to know if her life could have been saved.

Shrewsbury and Telford Hospital Trust has said it will update its policy following Mrs Davies's death.

The inquest had originally heard from Stuart Lillevitz, a nurse on the ward at the time, that the decision added an extra seven to 10 minutes to the journey. But after a test was carried out, the coroner heard that those times had been over-estimated.

The journey from the ambulance to ward 10 – on the first floor above the A&E department – actually added just under three minutes to the journey at most.

Mr Ellery said: "On the basis that seven minutes would not have made any difference, this evidence actually reduces any possibility of any delay being significant."

The inquest at Wellington Civic Centre also heard a statement from Violet Redmond, a member of staff at SaTH, who said a new section of the trust's sudden illness and collapse policy – currently in draft form – would make it clearer for staff where affected patients should be taken.

In a statement read out in court, she said: "SaTH will include a new section in the policy of sudden illness and collapse and it will make reference to the procedure for anyone who has a sudden collapse on trust premises, including anyone who has just been discharged and is being transported."

She added: "My understanding is it was thought it may have been appropriate for Eileen Davies to be taken to A&E, however it was not felt to be the optimum place as ward 10 knew her and her medical history."

Mr Ellery said although it was determined the extra journey time had not made a significant difference, "there was this gap in apparent procedure which is now being addressed".

Mrs Davies was assessed on January 29 and told she was able to return to her home in Lowe Court off Wellington's High Street that day.

But as she was getting into an ambulance to take her home she went into cardiac arrest and collapsed.

Mrs Davies was then taken back to the ward she had left rather than the A&E department, which was much nearer.

Last month, Mr Lillevitz told the inquest how Mrs Davies seemed well on the day she was discharged.

"Everything was done to help Mrs Davies when she returned to ward 10 after going into cardiac arrest," he said.

At yesterday's hearing, Mr Ellery concluded the death was as a result of an accident and was contributed to by a broken shoulder caused by an accident fall.