“Mrs Tadman had dementia and a long-term catheter who was admitted to hospital with a…”

The coroner’s concerns

– 1. Mrs Tadman had dementia and a long-term catheter who was admitted to hospital with a pre-alert for suspicion for urosepsis that was treated appropriately. However, urine dipstick tests were only positive for blood and consideration was not given to the circumstances in which she was found with a history of a fall. 2. Evidence was heard at the inquest that ambulance crew noted and handed over Mrs Tadman’s left leg was rotated but not shortened. Mrs Tadman could not stand or mobilise to use the commode in hospital. No consideration was given to a potential fracture injury. 3. Mrs Tadman was an elderly lady with a medical history of osteoporosis who fell from a standing height. No imaging was conducted on admission to hospital to establish if Mrs Tadman had sustained an injury. 4. Swelling in the calves gave rise to a suspicion of potential deep vein thrombosis and dalteparin was prescribed. Physical examination was over reliant on the lack of complaints of pain in a patient with dementia in the absence of imaging. 5. There was no consideration of potential fracture or internal bleeding in the presence of dropping of haemoglobin and continued deterioration. 6. The Trust did not conduct a serious incident investigation following Mrs Tadman’s death when the post-mortem cause of death established a pelvic fracture with severe haemorrhage. Evidence heard at the inquest confirmed that this case was not discussed at the trust morbidity and mortality review or any other forum giving rise to concerns that lessons had not been learned.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2021-0023

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0