Woman dies after injury allegedly overlooked

A woman died in Tauranga Hospital of a spinal injury after an x-ray six days beforehand did not reveal such an injury, an inquest has been told.

A coroner's inquest at Tauranga District Court is probing the death of 57-year-old Te Ata Iraia Hammond, who died on April 11, 2003, from a spinal injury that damaged arteries carrying blood to her brain.

Doctors who examined her at the hospital said they did not see any evidence of a spinal injury when they first examined her, six days before her death.

The doctors said the x-ray was unclear because of Ms Hammond's age and because it did not show the whole length of the spine.

Ms Hammond, a resident of Oceanside Resthome in Pukehina, had suffered a stroke earlier in her life, giving her a mental age of between seven and 10.

Eight people gave evidence at the inquest in front of Tauranga coroner Michael Cooney on Friday before it was adjourned so the resthome manager, who was in the South Island, could also give evidence.

Leanne Best -- the resthome's resident nurse -- told the court Ms Hammond fell out of bed just before 7am on Saturday, April 5.

Mrs Best called an ambulance and Ms Hammond was taken to Tauranga Hospital. She was examined by doctors and discharged.

Michael Blundell, who now lives in England, was the first doctor to examine Ms Hammond that morning.

In a statement read by Detective Sergeant Todd Pearce, Dr Blundell said he examined an x-ray taken of Ms Hammond's spine that morning, but did not see any sign of an injury.

However, a more detailed x-ray taken three days later did show a fracture.

It was not clear if this was the result of the initial fall or another she had after she was first examined.

Derek Sage, a doctor, said Dr Blundell had examined her to the best of his experience and, with the x-ray available, could not find an injury.

Dr Sage said Dr Blundell's actions were reasonable for his level of experience.

Dr Martin Sage -- the Tauranga pathologist at the time of Ms Hammond's death and who is not related to Dr Derek Sage -- said he carried out an autopsy and found evidence of damage to her spine that was both the result of her age and possibly one or two falls.

Dr Andrew Hill said he could see no injury to her spine when he examined her in the emergency department. He also re-examined her at the hospital on April 7.

Dr Hill said the resthome manager told him by phone that Ms Hammond had been unsteady on her feet since the initial fall and she believed Ms Hammond had suffered another fall at the home after returning from hospital.

Mrs Best said Ms Hammond appeared to be in pain on April 6 and had lost her appetite. At 3am, Mrs Best heard Ms Hammond calling from her room. Mrs Best found Ms Hammond could not move and thought she had suffered a stroke.

She was re-admitted to the hospital and died on April 11.

Dr Clinton Pinton, a consultant radiologist at the hospital, said he examined the first x-ray taken of Ms Hammond from the previous Saturday. He said he saw no evidence of an injury to her neck or spine.

The inquest is likely to resume in June.