A CATALOGUE of failures in treatment meant Patrick Byrne, 87, who had lived in Melksham for more than 50 years, died paralysed and in pain after doctors at Bath’s Royal United Hospital failed to diagnose a neck fracture.

But his family were shocked when coroner Peter Harrowing recorded a verdict of death by natural causes, despite saying there had been ‘serious failures’ in his care. Mr Byrne’s daughter, Elizabeth Porter, said: “We were shocked at that verdict. After he listed all those failures we could not believe he did not say it was negligence.”

Yesterday the trust which runs the RUH issued an apology to the family, saying: “We acknowledge that we did not always meet our own high standards of care on this occasion.”

Mr Byrne was first taken to the hospital on May 23 last year, after a fall at his home in New Lawns, Melksham.

The inquest heard that he suffered the fracture, which went unspotted by staff, and even discharged him to Chippenham Community Hospital, in mid-June, despite a nurse highlighting his frailty and drooping head a day earlier.

Following a collapse in Chippenham, Mr Byrne was returned to the RUH but continued to be misdiagnosed, with staff not responding to pleas from the family to have his drooping neck scanned until July 6, by which point he had become paralysed. He died in hospital on October 21.

A number of faults in his care emerged during the two-day inquest, including weekend staff shortages on acute wards, speculative diagnostic suppositions which later became firm diagnoses without proper research, poor record keeping and basic deficiencies in communication.

Despite this, Mr Harrowing found the hospital’s care did not reach the point of negligence as he believed the paralysis and his eventual death were not preventable.

The family are dismayed by the verdict, labelling it bizarre and saying they fail to understand how the coroner could not see the hospital’s care as negligent.

Outside the court in Flax Bourton, Mrs Porter, who was at the hearing with her sister Breda Byrne, said: “We are still struggling to come to terms with dad’s death, most of all because we cannot escape the fact that he suffered considerably before he died.

“The standard of care my father received fell well below what should have been expected and, if the neck fracture had been diagnosed earlier, he could have had treatment which would have avoided the paralysis and his last months would not have been as distressing.

“The evidence was there. There were a lot of failures. He had been in hospital for a month before any diagnosis was made, despite his head being slumped on his chest.”

Suming up, Mr Harrowing said: “There are a number of areas that give me cause for concern in the care of Mr Byrne.

“There are diagnoses which have been proposed which later became firm diagnoses. There was a lack of consideration of prior medical records even relating to a prior admission to the hospital.

“I have heard evidence that there were examinations of which no record was kept. While one might understand junior medical staff not making a record I find it difficult that experienced consultants would do so.

“That the spinal cord compression of Mr Byrne was not acted upon was a serious failure. It does raise in my mind concerns as to staffing levels and actions that can be taken at the hospital at the weekend.

“I have to say I have come very close to finding neglect in this matter. However, Mr Byrne was a frail gentleman and the evidence I have heard was the collapse could not have been prevented.”

Following the inquest Helen Blanchard, director of nursing and midwifery, spoke on behalf of the Royal United Hospitals Bath NHS Foundation Trust, saying: “We would once again like to offer our deepest condolences to Mr Byrne’s family at this difficult time. We acknowledge that we did not always meet our own high standards of care on this occasion and for this we apologise.

“The coroner was satisfied that we have already addressed a number of the concerns highlighted by the inquest. We will now reflect on the coroner’s observations and act on the further learning opportunities identified.”