Fatal head injury 'fell through the net' at A&E

AN accountant who died from bleeding on his brain would have had a good chance at survival if a scan had been carried out within a few hours of his admission to hospital rather than two days later, an inquest heard.

John Bailey, aged 37, suffered a head injury in a fight six weeks before he went to Barnsley General Hospital complaining of severe headache, vomiting and hallucinations.

He had been treated at the same accident and emergency department the previous month but the doctor who saw him on the second occasion did not know about the earlier head injury.

A Sheffield inquest heard a repeat visit would only be flagged up on patient records if he had returned within two weeks. Details about the head injury "fell through the net."

Recording a narrative verdict, assistant deputy coroner Prof Robert Forrest said he planned to write to the Royal College of Emergency Medicine about the systems in emergency departments to alert professionals to previous attendances.

He said in Mr Bailey's case "a lack of easily available records led to inappropriate clinical decisions being taken".

Mr Bailey's sister Tracy said she and the family missed her "quiet and generous" brother every day.

"We are so upset and angry that had the accident and emergency department accessed his notes he would have had treatment sooner and he most likely would not have had to die."

Mr Bailey hit his head when he was pushed outside the Dearne Hotel, on September 15 2007.

He was admitted to the medical admissions ward early on October 20. If staff had knowne of the head injury, he would have remained in the care of the emergency medicine team.

Dr Julian Humphrey, consultant in emergency medicine, said a CT scan would have been done that morning.

"The waters were so muddy the only way was to get a scan to find out what was going on in this man's head," he said.

Mr Bailey, from Ringway, Bolton upon Dearne, did not have a CT scan until two days later, after a lumbar puncture that could have exacerbated his condition ruled out meningitis.

The scan showed major bleeding on his brain, which was under a lot of pressure. He was immediately transferred to the Royal Hallamshire Hospital for surgery.

But there was no improvement in his condition and he was certified brain stem dead. His life-support machine was switched off on October 25.

Mr John McMullen, consultant neurosurgeon at the Hallamshire, said Mr Bailey's chances of survival would have been good had he undergone the scan earlier and been sent for the operation sooner.

"The surgery always carries a risk - but the risk of death and stroke was low," he said.

Dr Humphrey admitted Mr Bailey's head injury had "fallen through the net" and said the hospital is developing a new administration system looking at how previous attendances can be flagged up.


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