Patient at Walsall Manor Hospital died 12 hours after hospital scan

He was admitted to the hospital suffering with shortness of breath and had recently lost two stone. Tests were carried out, but the results of a CT scan were not immediately acted upon. Twelve hours after the scan, the man went into cardiac arrest and died.

The death was recorded as part of a serious incident report submitted for the board meeting of the Walsall Healthcare NHS Trust on Thursday.

The report also revealed that two patients had a delay in their diagnosis of cancer following CT scans.

Speaking at the meeting of the trust, director of nursing, Rachel Overfield said: "We as a trust have discussed these incidents in private and now have brought them here in order to be more transparent. We had just shy of 1,000 incidents in April but these were of either no harm or minor harm. This is what experts would expect to see in a trust of this size. The main key trends in the data is poor documentation issues and particularly an increase in falls.

"There has also been an issue with equipment in maternity and delays in acting on abnormal scan results. We also had cases of pressure ulcers, though some of these were out in the community, and a case of norovirus in April. There were incidents that were clearly unexpected and now we will be introducing a nominated lead for the safety team in order to address these."

Amir Khan, Medical Director for Walsall Healthcare NHS Trust, said: "We would once again like to offer our condolences to the family on their loss. The trust carried out a full investigation which concluded that some elements of this gentleman's care required improvement. An action plan was developed as a result and this is something that our staff across all levels of the organisation have learned from. The incident was also referred to the coroner's office which gave the cause of death as natural causes and did not require an inquest to be held.Throughout the investigation I have maintained close contact with the family and am happy to meet with them again if they have any further queries or concerns."

The man's death in 2015, was recorded in the report as a 'diagnostic delay'. It stated: "Tests were carried out to assist diagnosis, but the results of a CT scan were not immediately acted on. 12 hours after the scan had been reported the patient went into cardiac arrest, CPR was commenced but sadly this was unsuccessful." The was listed as a 'closed incident' among others where lessons have been learned.