Man’s death ‘could have been avoided’

Edwin Hilfiker, 81, of Lancing, died on October 19 at Worthing Hospital following a significant bleed on the brain.

An inquest into his death at Centenary House, in Durrington, on Wednesday, heard his GP had associated his headaches and a fall with a urine infection.

Coroner Dr Karen Henderson said Shoreham GP Dr Christopher Huckstep had not fully explored his patient’s symptoms or documented discussing a fall – describing his actions as ‘a failing’.

Mr Hilfiker’s wife, Mary-Rose, told the court: “I explained about his terrible headaches as he did his urine sample. I said he had a bad fall and knocked his head.

“Dr Huckstep didn’t question him and only said the fall would come with a bladder infection.”

Mr Hilfiker had a routine appointment at The Lyons Practice, in Pond Road, on October 16, but had fallen at home in the early hours.

Dr Huckstep told the inquest he could not recall the consultation but accepted his note-taking could have been better.

Later that day, Mr Hilfiker’s condition worsened and his son, Mark, believed he had suffered a stroke. He attended Worthing Hospital A&E but was later discharged.

The inquest heard ‘irreconcilable’ evidence that Mrs Hilfiker had told Dr Savintha Nagaraju about the fall but she insisted it was never mentioned.

A&E consultant Dr Mandy Grocutt said the hospital’s treatment would have been different had they known about the fall.

She said: “If we had heard there had been a fall and a significant one at that, it would have changed what we had done on October 16. At no time on the records is there a record of a fall being mentioned.”

Mr Hilfiker was taking blood-thinning drug warfarin for an irregular heartbeat, which heightened the risk of a bleed.

NICE guidelines for CT scans now dictates Mr Hilfiker would have been automatically eligible for a CT scan as a result. But at the time, this was not the case.

On October 18, Mr Hilfiker had another fall. He was rushed to hospital, where a CT scan was performed.

The scan confirmed he had suffered an acute subdural haematoma and it was untreatable. He died in the early hours of the next day, with his son by his bedside.

Expert witness and neurosurgeon John Norris believed Mr Hilfiker would ‘probably have survived’ had intervention been sought before October 17.

In recording a verdict of accidental death, Dr Henderson said: “I find an incident of a fall was mentioned to the GP.

“While the evidence is finely balanced, on the balance of probabilities it was not fully explored, simply for the fact there was no documentation to say it had been. I find that this is a failing.”

She added: “We heard evidence that if there was an understanding he had a head injury and a fall that there would be an expectation that a CT scan would have been carried out.

“If he had surgery and he was under close observation he would not have died when he did. That is very clear.”