THE DEATH of an elderly woman has been attributed to a brain haemorrhage missed by a radiologist at Great Western Hospital in Swindon, after she fell and hit her head.

June Rose Pike, 84, of Lainey’s Close, Marlborough, was an in-patient at GWH in Swindon on February 19 this year when she tripped over a chair leg, hitting her head on a windowsill, as she was helping another patient to the bathroom. Mrs Pike died on February 28 after suffering a large bleed on her brain which resulted in a haemorrhage.

The inquest into her death, which took place at Wiltshire and Swindon Coroner's Court in Salisbury yesterday heard how Mrs Pike had received a CT scan at the hospital which was incorrectly read, showing her to be in a normal state of health.

Mrs Pike was discharged on February 19 but then readmitted on February 21 after becoming ill whilst at home with her daughter.

In a statement from Lisa Darrell, a clinical fellow at GWH, said: “I was told that she fell whilst on Jupiter Ward and suffered a head injury, she was then sent for a CT scan which showed as normal. She had been very chatty but then became confused. There were no reports of slurred speech but she began to vomit when she was at home, an ambulance was called and June was brought back to GWH.

“A second CT scan showed a large haematoma so John Radcliffe Hospital in Oxford was contacted. As she was on anti-coagulants it was advised not to operate as it was too risky so it was agreed with her family to begin end of life treatment and to make her comfortable.

“We would not have sent her home if we didn’t think she wasn’t suitable to be discharged.”

The inquest then heard from Dr Alvyn Troughton, the consultant radiologist at GWH who had been the doctor to review the initial CT scans.

“There were 180 images of the scan from June, so there were a lot to review. There can be distractions when reviewing the scans, such as the phone going or someone asking you to have a look at other scans,” said Dr Troughton.

“As people get older they can find themselves going through cerebral atrophy, when the brain gets smaller inside the skull, leaving space and fluid between the two. There is a policy when discrepancies are reviewed by colleagues if things get missed.”

Mrs Pike's daughter, Deirdre Atkinson, questioned the doctor on how a bleed on the brain could be missed, something which led to the haemorrhage and death of her mother.

“It is easy to get distracted when carrying out reviews of scans, if the phone goes when you are looking at one your brain will then tell you that you have reviewed it fully. We are very busy but I do not like to use busyness as an excuse. It’s a relatively high stressed job but that doesn’t change the fact that I missed it,” said Dr Troughton.

Since the death of Mrs Pike, the hospital has since added a new position to the radiologist department to help prevent a similar incident taking place again.

Assistant coroner for Wiltshire and Swindon, Claire Balysz, said: “My conclusion will be narrative. June was discharged on February 19 after suffering a fall in the early hours. A CT scan she received incorrectly showed normal results. After being sent home, she was readmitted and a further CT scan showed a large bleed.

“The decision was made to start end of life care and she passed away on February 28 at Great Western Hospital. I would like to express my sincere condolences to the family of Mrs Pike.”

In a statement, the Great Western Hospitals NHS Foundation Trust said: “We offer our deepest sympathies to Mrs Pike’s family and have since met to apologise and talk through what happened.

“As a result of our investigation we have now introduced protected time for our clinicians to review CT images and work is also taking place to improve staffing levels.”