Coroner warns Tauranga hospital again

Bay of Plenty coroner Michael Cooney has issued a stern warning to Tauranga Hospital after the death of an elderly woman in its care.

Mr Cooney was speaking at the inquest into the death of Te Ata Iraia Hammond, 57, who died on April 11, 2003 from a spinal injury that damaged arteries carrying blood to her brain.

Mr Cooney cleared the doctor who examined her of any wrongdoing but he criticised the hospital for not having already implemented procedures that he had previously recommended for the Accident and Emergency department.

"I do not understand the reason for the delay in the adoption of such protocol," he told the hospital's lawyer, Mark Beech.

The inquest into Ms Hammond's death started on April 8 when hospital doctors said they did not see any evidence of a spinal injury when they first saw her, six days before her death.

Doctors said the x-ray was unclear because of Ms Hammond's age and because it did not show the whole length of the spine.

The inquest was then adjourned and resumed last Friday so the manager of the Oceanside Rest Home in Pukehina, Raewyn Lynstrum, could give evidence.

Mrs Lynstrum said Ms Hammond moved into the rest home in 1986 and had been in their care for 17 years. On April 5, 2003 she was told Ms Hammond had fallen out of bed.

She believed Ms Hammond probably fell from a standing position in her room rather than out of bed. Ms Hammond had never fallen out of bed before and it was low to the floor to minimise that risk.

Mrs Lynstrum said she offered to help the hospital with Ms Hammond's care because the patient had earlier suffered a stroke and had a mental age of around seven to 10 years' old.

Ms Hammond also had a habit of giving answers to people that she hoped would please, which could create difficulty in reaching a diagnosis.

Her offer was declined.

Mrs Lynstrum said she next saw Ms Hammond when she was discharged that evening. She seemed to be in some pain.

The next morning Ms Hammond had to be spoon fed her cereal and was re-admitted to the hospital. Later a doctor called the rest home to ask why they had sent her back when the doctors could find nothing wrong.

Ms Hammond died in hospital on April 11.

Mr Cooney concluded Ms Hammond died from a spinal injury that damaged arteries carrying blood to her brain when she fell sometime between April 5 and 7.

He said the fracture was hard to see on the x-rays taken because of the location of the damaged vertebra. The problems were also compounded by Ms Hammond's mental age as it was hard for her to explain what was wrong.

- BAY OF PLENTY TIMES