Woman died after medics failed to treat her broken collarbone at Essex hospital

An 88-year-old woman died after medics failed to deal with a fractured collarbone - even though it had showed up on an X-ray. Margaret Pilgrim died at the Princess Alexandra Hospital on June 29, 2023 - around three weeks after breaking her clavicle in a fall at home.

The break showed up on an X-ray but was not included in her notes when she was discharged from hospital on June 4 - the day after she was admitted following her fall. It meant pain relief was not prescribed until June 6 when her GP raised the concerns of the family with the trust.

A prevention of future deaths report said Mrs Pilgrim's health started to decline rapidly on June 10 “with delirium”.. She was given treatment with antibiotics and although a scan on June 19 showed no evidence of pneumonia Mrs Pilgrim remained unwell.

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Mrs Pilgrim was admitted into hospital and despite treatment continued to decline with “intermittent delirium”. An inquest found she died from heart failure and bronchopneumonia.

The prevention of future deaths report found that “the trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package”.

It added: “The discharge summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked. The fracture was only confirmed when the GP raised the concerns of the family with the trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic.”

Finola Devaney, director of clinical quality and governance and assistant chief nurse (quality) at The Princess Alexandra Hospital NHS Trust, said: “We offer our deepest condolences to Mrs Pilgrim’s loved ones. We apologise for any gaps in her care and treatment, which impacted on her subsequent care.

“We are committed to learning from this incident and ensuring that improvements are implemented. We will be issuing a full response to the Coroner on actions taken by August 5.”