A CORONER has given health bosses 56 days to come up with a preventative action plan, after a hospital failed to spot that a pensioner who later died had a broken neck.

Donal Charles Brown, 87, from Ruardean near Ross, received CT scans at a Gloucester hospital after falling at home on January 31, 2021.

He was sent home after no fractures were reported, but still had neck pain and difficulty swallowing.

Mr Brown was then readmitted to hospital suffering with aspiration pneumonia on February 26, 2021, when it was spotted that he had a displaced fracture of the C2 vertebra with spinal cord compression, which was visible on scans from his first hospital visit.

Operative intervention was advised against by neurological experts, but the patient’s condition deteriorated and he died on March 4.

Senior coroner for Gloucestershire Katy Skerrett previously gave a narrative conclusion at an inquest last December into Mr Brown’s death, and has now sent a prevention of future deaths report to Gloucestershire Hospitals NHS Foundation Trust’s chief executive, raising concerns that could lead to more deaths in the future.

She said the severity of his broken neck probably caused the swallowing difficulties, leading to aspiration pneumonia, and raised concerns over the radiology department’s “significant understaffing” and a shortage of radiology trainee posts.

Other issues the coroner has raised include an hour limit for the reporting of all scans, including non-urgent, and delays due to cost in appointing call handlers to triage calls to reduce demands on radiologists’ time.

The NHS has 56 days to provide the coroner with details of action taken or proposed to be taken, or must explain why no action is proposed