A retired police officer died in an “avoidable accident” at an NHS hospital after his head was crushed between the rails and mattress of his hospital bed.
Max Dingle, 83, died 15 minutes after he was found “entrapped” in the bed at the Royal Shrewsbury Hospital on May 3 2020.
Concluding an inquest into Surrey-born Mr Dingle’s death, a senior coroner found resuscitation had not been attempted despite the pensioner electing for life-saving intervention and having a pulse when he was found.
Earlier this month, Shrewsbury and Telford Hospital NHS Trust, which runs the hospital, was fined £1,333,334 for failing to provide safe care to Mr Dingle and another patient who died in an unrelated case.
Senior coroner John Ellery said Mr Dingle, of Newtown, Powys, in mid-Wales, was originally admitted to hospital with “shortness of breath” on April 27, 2020.
His medical history showed he had suffered with a heart condition, lymphoedema and sleep apnoea.
The coroner said: “He remained in hospital until May 3, at 10am, when he was found with his head trapped between the rails and mattress of his hospital bed.
“He suffered a cardiac arrest – from which resuscitation was not attempted – and he died at 10.15am.”
Nobody from the hospital trust was present for the hearing but family members, including Mr Dingle’s son Phil, dialled in from Australia.
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Mr Ellery said an initial post-mortem examination gave a cause of death of heart disease “and did not consider the entrapment caused or contributed to the death”.
However, Mr Dingle’s son “did not accept” those findings, instead commissioning expert consultant forensic pathologist Johan Duflou, from the University of Sydney, to review the findings and post-mortem examination.
Prof Duflou gave a cause of death of “entrapment with positional asphyxiation”.
After comparing and discussing their findings, both pathologists then agreed “entrapment did play a significant part in the cause of death”, Mr Ellery said.
An inquest was opened and adjourned while separate criminal proceedings against the NHS trust were carried out by health watchdog the Care Quality Commission (CQC).
The criminal inquiry ended this month after the trust admitted failings in connection with the care of two patients, including Mr Dingle.
Concluding the inquest, Mr Ellery said: “Based on all the evidence, the conclusions of this inquest are Mr Dingle’s death was an avoidable accident.”
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