George Broadhurst

I am Alison Mutch, Senior Coroner, for the coroner area of South Manchester

On 12 th October 2023 I commenced an investigation into the death of  George Barry Broadhurst. The investigation concluded on the 30 th April 2024 and the conclusion was one of Narrative: Died from the  complications of a fracture sustained in an accidental fall where the  fracture was not recognised immediately. The medical cause of death was 1a) Pulmonary Embolism and Community Associated  Pneumonia 1b) Infected traumatic thoracic vertebral fracture 1c)  Fall.

George Barry Broadhurst lived independently and was mobile. Around  the 4 th September 2023 he had an accidental fall at his home address. He reported to his GP that he had injured his lower back and was in pain. He  was advised to attend A&E but declined. He managed with pain relief at  home. He continued to manage at home until 25 th September 2023 when  he went to Tameside General Hospital. An x-ray was taken. He was  discharged. The x-ray showed a fracture of the vertebrae but this was not  identified at that time. A radiologist reported on the x-ray 2 days later and  it was to be reviewed by a Consultant but was not done due to backlogs.  On 1 st October 2023 he went to Stepping Hill Hospital with worsening  back pain. The fracture was identified and he was discharged home with  pain relief and treatment for a lower respiratory tract infection and with  support in the community. At home he deteriorated rapidly. He was readmitted on 7 th October to Stepping Hill Hospital. He had a collapsed lung, pulmonary embolism and an infected fractured vertebra. The  collapsed lung and pulmonary embolism were as a consequence of lack of mobility due to the fracture. He deteriorated and died at Stepping Hill  Hospital on 10 th October 2023.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows.

1. The inquest heard evidence that the delay in reporting of X rays by

radiologists is not unique to Tameside but is a national picture  caused by a shortage of radiologists and trained reporting  radiographers. The impact of the shortage is that ED doctors are  interpreting x rays in highly pressured situations without specialist  input and with a consequential risk of missing more subtle  fractures. This means that patients are discharged with fractures  rather than appropriate treatment or conversely are given  unnecessary treatment that then has to be reversed once a  specialist review takes place.

1. The knock-on impact of the delay in reporting is that once the  radiology reports are available they then have to be reviewed in

conjunction with the notes by a consultant days after the  attendance to ensure the treatment given fits with the reported  findings. This is a significantly more time-consuming process than  them being looked at in real time and results in ED consultant  resource being diverted away from the day to day demands of ED. Thus, placing a greater strain on clinicians in ED and stretching  resources more thinly.

1. The evidence given was that the level of pain that Mr Broadhurst  still had in the community after 1

st October was not in keeping with a healing fracture. The inquest was told that it was important that  community/primary care teams were trained to understand how  “normal” pain, in the context of a fracture being managed in the  community, would present and what was a red flag/ deteriorating  situation. Training on expectations around healing fractures would  ensure what was a life-threatening deterioration was picked up and escalated at the earliest possible point.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.