Stroke patient, 97, not seen by specialist for three weeks

Elsie Martin, from Bushfield Court, Bilston, had been taken into New Cross Hospital on June 18 after fracturing her hip, following a fall at home.

She was operated on and placed on the A5 orthopaedic trauma ward at the hospital.

Mrs Martin had difficulty in swallowing and had been on a purée diet since a stroke in 2014.

While in the hospital, family members had requested for her referral to the Speech and Language Team (SALT) on several occasions, expressing their concern that she would not be able to eat the hospital's food, the Black Country Coroners Court heard.

Shortly before her death on July 13, it was revealed that the referral had not been made to the SALT until July 11.

An assessment was carried out on July 12.

It was claimed that ward staff had not had a response from the SALT team, despite bleeping and phoning them.

During her hospital stay, Mrs Martin developed a 'severe chest infection' resulting in sepsis.

The cause of death given was pneumonia, fracture following the fall and old age.

The court heard on the balance of probability, due to her chest infection she would not have recovered, even if she had been seen by a SALT member earlier.

The Royal Wolverhampton NHS Trust said that provisions had been made following the death including an email contact for SALT, the introduction of an electronic system and uploading patient reports.

Senior coroner Zafar Siddique gave a narrative conclusion, but said that the family had 'a battle' in getting through to nursing staff about Mrs Martin's requirements.

He said he felt content that no neglect should be ruled or no prevention for future deaths, due to the revisions already in place on the ward.

Distraught niece, Susan Adderson, from Wednesfield, said: "When I returned from holiday on June 28, she looked like someone who had come out of a concentration camp."