AN INQUEST into the death of a 92-year-old woman who was sent home with rib fractures, a punctured lung and a cannula in her arm, has found there were “significant failures in the diagnosis and treatment” she received.

Dorothy Violet Mancey, of Kings Terrace, Newport, was admitted to Withybush Hospital on March 24, 2013, after a fall at her home.

When paramedics arrived at 10.49pm, Mrs Mancey complained of pain in the right side of her chest, and an initial examination found bruising and reddening.

Her daughter Cynthia Fells accompanied her to hospital, where she was examined by a triage nurse, who recorded that Mrs Mancey was prescribed warfarin – a blood thinner.

The on-call doctor also recorded her prescription, and requested x-rays of Mrs Mancey’s injuries.

These were then referred to a senior colleague, following difficulty in interpreting them.

Mrs Mancey was discharged at 5.45am with a prescription of diclofenac – an anti-inflammatory - and her medical records filled in to say nothing abnormal had been detected.

In fact, the x-rays showed she had numerous rib fractures and a pneumothorax – punctured lung.

At home, Mrs Fells noticed a cannula had been left in her mother’s arm, and called the district nurse to remove it.

The district nurse told Mrs Mancey not to take the diclofenac, as it should not be given to patients already taking warfarin.

Following concerns by her family that the x-ray results had not been fully explained to them, the district nurse alerted Mrs Mancey’s GP, who recommended she return to hospital.

Mrs Fells said her mother refused because of the poor treatment she had received the previous day.

Mrs Mancey’s GP also examined the x-rays herself, and wrote to the hospital saying she believed they had been misread, and that the prescription of diclofenac was unsafe.

The GP visited Mrs Mancey again on April 3, and it was agreed she be admitted to Parc y Llyn nursing home.

Her condition deteriorated, and on April 12 she was re-admitted to Withybush Hospital, where she died on April 23.

Speaking at the inquest on Thursday, Claire Rawle - solicitor for Hywel Dda University Health Board - said there had been a full investigation into the care Mrs Mancey received three years ago, and all issues identified had been taken seriously and acted upon.

This included training to identify fractures and ensure patients were discharge correctly.

She said there had been ‘significant investment’ in specialist staff such as occupational therapists, and that care for the elderly would ‘continue to remain a priority’ for the health board.

Speaking on behalf of Mrs Mancey’s family, solicitor Maggie Hughes said: “When Mrs Mancey was admitted it was hoped these measures would have been in place and been acted upon that night.”

She added: “What will give them some comfort is that these inactions are not repeated in the future.”

Recording a narrative conclusion, Coroner Mark Layton said there had been “significant failures in the diagnosis and treatment” Mrs Mancey received.

But he felt the health board had done enough to ensure that “if this situation emerged today, it would be addressed in a different way”.