Coroner criticises woeful and unacceptable treatment of Mike Tindall’s grandmother
Margaret Shepherd died in Leeds General Infirmary, West Yorks, 10 days after she was hit by a car reversing into a parking space.
The 88-year-old relative of Tindall, who is the boyfriend of the Queen’s granddaughter Zara Phillips, suffered minor fractures in the incident in Kirkgate, Otley.
However, on the eighth day of her hospital stay in March 2006, she suffered a blood clot in an artery which led to a stroke.
West Yorkshire Coroner David Hinchliff yesterday issued a damning verdict of standards at the hospital after hearing that there was no record of Mrs Shepherd being seen by a doctor in her last 48 hours.
Recording a narrative verdict, Mr Hinchliff said: “Certain aspects of treatment were unacceptable and the notes were woeful.
“In the two days between her cerebral event and collapse Mrs Shepherd was not attended, examined or diagnosed by a doctor. This represents a serious omission by the clinicians.”
During the inquest at Leeds Coroner’s Court, doctors and consultants who dealt with the case maintained that Mrs Shepherd had been attended to, but that no notes had been made in her file.
Giving evidence, Dr Katrina Topp, a consultant physician on the case, said she had no explanation for the omission on Mrs Shepherd’s file on March 9 and 10.
She said: “I think in this individual case there is no entry on the 9th and 10th but I think the entries on the other days show good housekeeping. They are cases of concern as individual incidents.
“I don’t have an explanation but I agree it’s very poor. Some doctors have done a ward round and not recorded it in their notes, that needs to be addressed.”
Mr Hinchliff said: “If it is not in the notes then it hasn’t happened, if it is not in the notes there is no way I can speculate. This was a woeful absence, this is extremely unacceptable and the Trust will reap its own problems if this continues to exist.”
However. he added that if Mrs Shepherd’s condition had been diagnosed and treated, it would not have altered the outcome.
Following the verdict, Mrs Shepherd’s daughter, Linda Tindall, said: “It is now clear that reported concerns were not acted upon during these days. I would not wish anyone to be treated as my mother was as a patient on Ward 34 at the LGI. Nor would I wish their family members to suffer the aftermath of such an event.”
Leeds Teaching Hospitals NHS Trust issued a statement apologising to Mrs Shepherd’s family but denied that the problem was due to a systematic failure.