Death of nursing home resident ‘was preventable’, inquest finds

A coroner has ruled the death of a woman who was injured when a bus belonging to her care home came to an abrupt stop “was preventable”.

Joyce McCann, 77, was thrown from her wheelchair and landed on the floor of the vehicle as it “braked severely” to avoid a collision with a car in front of the bus in north Belfast.

She was treated in hospital for a fracture to her leg and a head injury following the incident on the Antrim Road on 19 September 2019.

The court heard Ms McCann was on an outing for ice-cream with other residents from Somerton homes in north Belfast when the incident occurred.

A post mortem examination of the 77-year-old revealed bleeding caused by two tears in her spleen was “the principal factor” resulting in her death.

The coroner said she found that Ms McCann’s death in hospital on 25 September 2019 was “preventable” on the balance of probabilities.

“On the evidence before me there were a number of missed opportunities in the care of the deceased by Somerton home, and in the care and treatment of the deceased at the Royal Victoria hospital.

The coroner added that if a “full CT scan” had been performed then a splenic injury “would have been diagnosed” and Ms McCann would have received a “different course of treatment” and this “would on balance have led to a different outcome”.

She said clinicians in the emergency department should have had a “high index of suspicion”, given that Ms McCann was an elderly patient who had been involved in a road traffic collision.

The coroner found that if the wheelchair had been tied down and “occupant restraint systems” been “correctly and effectively” fitted by the staff on the bus before travelling and if a “primary survey and whole body CT scan” had been performed at the hospital and if Ms McCann had been “reviewed by the senior clinicians” that “on balance” Ms McCann’s death “would have been prevented.”

The coroner added, “the deceased’s death highlights the risk that occult injuries in complex trauma cases can occur”.

“Therefore there is a need for clinicians to have a high index of suspicion and to exclude such injuries at an early stage, particularly in an elderly or vulnerable patient where the effect of these injuries may be more deleterious due to existing comorbidities.”

BBC News NI has approached The Belfast Trust for comment.

Somerton homes told BBC News NI it had no comment to make.

The coroner said she heard evidence from senior clinicians during the inquest “in relation to a number of changes that have been made in the Belfast Health and Social Care Trust following the deceased’s death”.

“I commend the Trust for the improvements it has made, following the death of the deceased.”

The coroner added that she hopes Ms McCann’s family “will take some comfort from knowing some lessons have been learned from the death of your beloved aunt so that another death in similar circumstances does not happen again”.