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A coroner has raised concerns about the medical treatment of an elderly woman at Huddersfield Royal Infirmary.

Coroner Charlotte Keighley has written to health trust bosses following the death of Kore Elizabeth Padgett, 90, who was admitted to Huddersfield Royal Infirmary in Lindley, Huddersfield following an accidental fall down stairs at home.

Kore had been fitted with a hard neck collar after she was diagnosed with an unstable fracture of her neck. However, she struggled with the placement of the collar and suffered pressure sores because of the pressure it caused.

Hospital staff were unable to appropriately adjust the collar as they had not been trained to do so, the coroner noted.

In a Prevention of Future Deaths report, the coroner said that hospital staff had sought advice from specialists in Leeds about the need for a collar and a request was made for Kore to be assessed within a week but this was not arranged.

Kore's health continued to deteriorate and she developed aspiration pneumonia, requiring chest physiotherapy which was limited by the placement of the collar.

No further contact was made with the specialist team in Leeds to discuss the ongoing effects of the collar on Kore's physical health and therefore Kore was unable to make an informed decision as to whether or not she wanted to continue wearing the collar or could remove it and accept any associated risks, the coroner's report noted. Kore went on to develop recurrent aspiration pneumonia and on the October 23 last year, despite having previous periods of improvement, her condition rapidly deteriorated and she died. An inquest concluded that Kore died from natural causes contributed to by injuries sustained from a fall requiring immobilisation in a hard collar.

The coroner has now raised four matters of concern and has asked Calderdale and Huddersfield NHS Foundation Trust to respond by October 23.

The four matters of concern are:

The absence of training for staff on the ward in respect of the correct fitting of a hard collar The absence of communication by clinicians with the neurosurgical team at Leeds in respect of treatment options for Kore given the significant impact that the collar was having, with the development of pressure sores, difficulties with swallowing and increasing risks of aspiration The absence of any consideration of the risks versus benefits of wearing the collar and consequently the lack of opportunity for Kore to consider the risk versus benefits and make an informed decision as to how she wanted to proceed The lack of communication between professionals providing care on the ward and the concerns they were raising as to the impact of the collar upon Kore's health and the absence of any consideration of those concerns by those in charge of Kore's care with no multi-disciplinary approach as to the available treatment options or further assessments which could have been undertaken

In a statement, Neeraj Bhasin, Medical Director, Calderdale and Huddersfield NHS Foundation Trust said: "Our sincere condolences go out to Kore's family. We are currently reviewing the information in this report."

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