Shropshire Star

Death of pensioner who became trapped in Shrewsbury hospital bed was 'avoidable'

A retired police officer died of an "avoidable accident" after his head and neck became trapped in a hospital bed, a coroner has ruled.

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Max Dingle died after becoming trapped in a bed at Royal Shrewsbury Hospital

Surrey-born Max Dingle, aged 83, died after he was found trapped in the bed at Royal Shrewsbury Hospital on May 3, 2020, six days after being admitted with shortness of breath.

A 20-minute inquest held at Shirehall, Shrewsbury, on Tuesday was told that a family member living in Australia challenged an original post mortem finding that Mr Dingle died of natural causes. At the hearing, Senior Coroner John Ellery found resuscitation had not been attempted despite the pensioner electing for life-saving intervention and having a pulse when he was found.

Mr Dingle's son, Philip, engaged Professor Johan Duflou, at the University of Sydney, after disagreeing with the result of a UK post mortem carried out by Dr Angus McGregor, a consultant histopathologist.

Dr McGregor had concluded that Mr Dingle, from Kerry near Newtown in Powys, had died of natural causes and that Mr Dingle's death was not caused by his head being trapped. This would have meant no inquest would be held, the coroner said.

But Professor Duflou came to a different conclusion, that the entrapment had been the main cause, with heart disease as a secondary cause.

Mr Ellery said the two experts then discussed their different results and decided on a joint cause of death, being entrapment and a cardiac arrest.

In a pre-prepared statement Mr Ellery said a Care Quality Commission investigation was launched, which concluded there had been a breach of health and safety legislation.

Shrewsbury and Telford Hospital NHS Trust (SaTH) was prosecuted, and earlier this month admitted failings in the deaths of Mr Dingle and 31-year-old Mohammed Ismael ‘Bolly’ Zaman, who died after suffering severe blood loss while undergoing dialysis in 2019.

The trust was fined £1.3 million at Telford Magistrates’ Court, the equivalent of one day's running costs, when a judge imposed an £800,000 fine relating to the death of Mr Zaman and £533,334 in relation to Mr Dingle’s death.

In a victim impact statement which was read to the court during the prosecution earlier this month, Philip Dingle said he and his father had shared a “very special bond” for 57 years.

He also paid tribute to the retired police office as a “mountain of a man” who was always the source of great advice.

The pensioner’s son flew back to the UK from his home in Australia to visit his father, but was told he had died before having chance to see him.

His victim impact statement read: “Dad’s death was a total shock to me. I had been told he was responding positively (to treatment).”

Philip Dingle said he been left with a sense of injustice and an image of his father dying an unnatural death “similar to someone in quicksand," adding: “It seemed that the Trust were trying to whitewash what occurred."

Following the trust’s guilty plea and sentence at Telford Magistrates Court, the watchdog’s director of operations for the Midlands, Fiona Allinson, said: “People using health and social care services have the right to safe care and treatment, so it’s unacceptable that patient safety was not well managed by Shrewsbury and Telford Hospital NHS Trust.

Director of nursing at SaTH, Hayley Flavell, said at the time: “A series of immediate actions were implemented following internal investigations and external review to ensure that steps were taken to address the failings, which has been recognised in the judgement.

"On behalf of the trust, I want to stress again how sorry we are for the pain and distress caused to the families and we commit to continue to improve the quality of care we provide.”

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