A DAMNING report into how a 91-year-old woman fell out off her hospital trolley, broke her leg in two places and died two weeks later has listed a catalogue of failings by the Great Western Hospital.

The independent investigation by the Healthcare Commission into Ella Sheppard's fall from a trolley in the hospital's accident and emergency department in 2003, said an internal investigation was deeply flawed, while misleading information was given to Government investigators.

And the report says improvements still need to be made.

Mrs Sheppard, of Ferndale Road, was admitted to hospital after falling down the stairs at her home, on September 30, 2002.

At 2am the next morning she fell from her hospital trolley, after being left alone to use a bedpan.

She was given an X-ray and found to have broken two bones in her left leg.

The next day, Mrs Sheppard's sons, John, 69 and Chris, 63, were told by one doctor the fractures were old, but another said it was a recent break.

The brothers became suspicious about how their mother's fall had been treated and started to investigate by making a complaint to the hospital, then appealing to the Health And Safety Executive and medical watchdog the Healthcare Commission.

The Healthcare Commission report said that although an X-ray revealed a double fracture to Mrs Sheppard's left leg, the Swindon and Marlborough NHS Trust only reported minor cuts on her head to the Health And Safety Executive.

The first letter sent to the brothers by the hospital confirmed the radiologist had diagnosed the breaks as recent and apologised for the accident.

The trust's health and safety adviser John O'Donnell told investigators breaks were not reported, because Mrs Sheppard already had a bandage on her left leg before her fall.

But the investigation said: "There was nothing to suggest this was the case in the notes and the family who were with Mrs Sheppard in A&E have not mentioned it."

The Healthcare Commission report concluded: "The systems in place at the trust at the time of Mrs Sheppard's admission were insufficient to deliver preventative measures that would ordinarily be expected in an A&E department treating an elderly lady with a history of falls.

"The trust's investigation following Mrs Sheppard's fall was deeply flawed. The opinions expressed by Ben Aslam, A&E consultant and Sue Malloy, A&E matron were unchallenged, while the opinion of Gail Powell, chief radiographer was ignored.

"This discrepancy was key to the investigation.

"The comments of Mr O'Donnell make clear he remains convinced the fractures sustained by Mrs Sheppard occurred prior to her arrival at A&E. Yet the basis by which he has arrived at his conclusion is unsound.

"The information provided to the HSE by the trust was misleading. While some of the statements were factually accurate, they were also vague. The statements made to the HSE significantly downplayed the events and cannot be considered to be a comprehensive, objective account on which an external organisation could make findings."

The report also said new measures to prevent vulnerable people from falling, introduced since Mrs Sheppard's accident, were still unsatisfactory and posed a substantial risk to patients.

John Sheppard said:"This is a damning report. If we hadn't made a fuss nothing would have happened."

Mr Sheppard said the family now did not know whether the fall contributed to Mrs Sheppard's death.

The report said: "It has not been possible to conclude whether the appropriate information was provided by the trust to the coroner.

"The Sheppards complained that the trust informed the coroner that the fractures occurred before Mrs Sheppard's arrival at the hospital.

"Given the comments of the pathologist at post mortem this cannot be discounted."

  • SWINDON and Marlborough NHS Trust admitted liability for the death of teenager Graeme McGinn in January.

Doctors at GWH failed to spot the16-year-old had internal bleeding following a motorcycle crash in 2004.

The McGinns were offered £10,000 compensation for allowing Graeme to die from a detached kidney, because he was only being treated for a broken arm.