A MARLBOROUGH woman died after a radiologist at Great Western Hospital in Swindon missed spotting a brain injury, after she fell and hit her head whilst a patient at the hospital.

June Rose Pike, 84, of Lainey’s Close, died on February 28 after suffering a large bleed on her brain which resulted in a haemorrhage, the inquest at Wiltshire and Swindon Coroner's Court in Salisbury heard yesterday.

Surgery to correct the condition was deemed 'too risky' because of the drugs she was taking.

Now the hospital trust have apologised to her family, promised to give doctors more time to look at scan images so mistakes do not happen again, and have taken on more staff in the radiology department.

Mrs Pike was a patient at GWH when she tripped over a chair leg, hitting her head on a windowsill, as she was helping another patient to the bathroom, nine days before her death.

The hospital carried out a CT scan which gave her the all-clear and sent her home, but a second scan after she was re-admitted when she became ill at home and rushed back to the hospital by ambulance showed a large haematoma, or bleed on the brain.

GWH doctor Lisa Darrell told the inquest in a statement: “She fell whilst on Jupiter Ward and suffered a head injury, she was then sent for a CT scan which showed as normal. She had been very chatty but then became confused.

“We would not have sent her home if we didn’t think she wasn’t suitable to be discharged.

“A second CT scan showed a large haematoma so John Radcliffe Hospital in Oxford was contacted. As she was on anti-coagulants it was advised not to operate as it was too risky so it was agreed with her family to begin end of life treatment and to make her comfortable.”

Mrs Pike's daughter Deirdre Atkinson, questioned Dr Alvin Troughton, the consultant radiologist at GWH who had been the doctor to review the initial CT scans, on how a bleed on the brain could be missed.

“It is easy to get distracted when carrying out reviews of scans, if the phone goes when you are looking at one your brain will then tell you that you have reviewed it fully," he replied.

"We are very busy but I do not like to use busyness as an excuse. It’s a relatively high stressed job but that doesn’t change the fact that I missed it.

“There were 180 images of the scan, so there were a lot to review. There can be distractions when reviewing the scans, such as someone asking you to have a look at other scans.

“As people get older they can find themselves going through cerebral atrophy, when the brain gets smaller inside the skull, leaving space and fluid between the two. There is a policy when discrepancies are reviewed by colleagues if things get missed.”

Since Mrs Pike's death, the hospital has taken on extra staff in the radiology department .

Assistant coroner for Wiltshire and Swindon, Claire Balysz, recorded a narrative verdict, saying: "June was discharged on February 19 after suffering a fall in the early hours. A CT scan she received incorrectly showed normal results. After being sent home, she was readmitted and a further CT scan showed a large bleed.

“The decision was made to start end of life care and she passed away. I would like to express my sincere condolences to the family of Mrs Pike.”

A spokesman from GWH said: “We offer our deepest sympathies to Mrs Pike’s family and have since met to apologise and talk through what happened.

"As a result of our investigation we have now introduced protected time for our clinicians to review CT images and work is also taking place to improve staffing levels."