Poor communication between a psychiatric ward and Northampton General Hospital contributed to the death of a patient whose broken back went unnoticed, an inquest jury has found.
Claire Masters had a history of paranoid schizophrenia and after an incident where she tried to harm herself on September 5, 2014, she was admitted to the Harbour Ward of Berrywood Hospital.
The 57-year-old made numerous attempts to harm herself while at Berrywood including what she described to doctors as “throwing herself from her chair onto the floor” and “banging her head”, the inquest heard.
But despite her openly telling nurses she had broken her back, two fractures were not diagnosed until September 26, when Miss Masters collapsed and suffered a respiratory failure.
Doctors at Northampton General Hospital (NGH) discovered she had suffered two fractures to her spine and she died on October 16 as a result of a subsequent infection. Those fractures could have occurred several days earlier.
In a wide-ranging case the jury heard how many nurses on the Harbour Ward at Berrywood may have had “negative attitudes” towards Miss Masters, and some did not believe her when she said she had broken her back.
A damning report into the care she received labelled the ward as “dysfunctional.”
Yesterday, the jury was tasked with delivering a narrative verdict on how Miss Masters came about her death and what were the “contributing factors”, coroner Belinda Cheney told them.
The jurors determined the cause of her death was a “respiratory tract infection, secondary to a spinal fracture.” It also identified there were a number of failures in the care provided by Northamptonshire Healthcare NHS Foundation Trust, which runs Berrywood Hospital, in providing care for Miss Masters.
The conclusion read: “It is evident that two-way communication between the Harbour Ward and Northampton General Hospital was inadequate, lacking consistency and specific related information regarding her back pain.
“This would have contributed to her suffering, care and treatment.”
In her summing up yesterday, Ms Cheney asked the jury to consider a number of points
“When Claire Masters complained of her back pain, was it recognised by Harbour Ward staff and did they give the relevant information to NGH?”, She said.
“Why wasn’t the critical fracture diagnosed until September 26?
“Might there have been a different treatment plan that changed the outcome?”
Ms Cheney told the inquest it has never been ascertained exactly when the fractures occurred, though consultants evidence suggested the first of the two could have occurred as early as September 9, 17 days before it was discovered.
She said “considerable force” would have been needed to cause the fractures.
Releasing a statement following the conclusion of the inquest late yesterday evening Northamptonshire Healthcare NHS Foundation Trust (NHFT) says it has taken “significant steps” to meet all of the concerns arising from the inquest.
Chief operating officer at the trust, Richard McKendrick, said: “We have undertaken an unprecedented amount of work since 2014 to improve standards of care, and we will continue to work with our partners in acute care to make further improvements where needed.
“While our senior management have been in regular contact with the family since 2014, as a Trust, we would like to take this opportunity to again offer our deepest condolences to Ms Masters’ family.”