A PENSIONER from the Forest of Dean died after the hospital treating him failed to spot he had a broken neck, a coroner has said.

Katy Skerrett, the senior coroner for Gloucestershire, sent a prevention of future deaths report to the chief executive of the Gloucestershire Hospitals NHS Foundation Trust.

In it, she highlighted concerns that could lead to more deaths in the future.


The coroner had previously recorded a narrative conclusion when an inquest was held into the death of Donal Charles Brown, an 87-year-old from Ruardean, in the Forest of Dean near Ross-on-Wye.

He had fallen at his home and was taken to hospital where CT scans were carried out.

No fractures were reported and after further investigations, was sent home.

But he still had neck pain and difficulty swallowing, and less than a month later was readmitted to hospital where he was treated for aspiration pneumonia.

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It was then noticed he had suffered a displaced fracture of the C2 vertebra with spinal cord compression, an injury which could be seen on scans from his first hospital visit but was not reported.

The coroner said it was likely that the severity of this injury led to his swallowing difficulties and caused aspiration pneumonia.

Neurosurgical opinion was sought and advised against operative intervention, with Mr Brown's condition steadily worsening before his death on March 4, 2021.


An inquest was then concluded on December 13, 2022, and a prevention of future deaths report was sent on January 31, 2023.

She was concerned about the "significant understaffing" of the radiology department and the national shortage of radiology trainee posts.

She was also concerned about the expectation that the reporting of all scans, including non-urgent, should be done within an hour and the appointment of call handlers to triage calls to reduce the demands on the radiologists’ time had been delayed due to cost.

The NHS was given 56 days to respond with details of action taken or proposed to be taken, setting out the timetable for action.

Otherwise, it must explain why no action had been proposed.