Bleed on the brain 'overlooked' after man collapsed outside High Street pub - inquest

Robert Green, from Sandfield Road, Stourbridge, died in Russell's Hall Hospital on August 25.

Black Country Coroners court heard how a second CT scan was ordered after Mr Green had 'declined rapidly' while in hospital.

The report of the first had been conducted by a radiologist based in Sydney, Australia, who worked for an external company who reviewed overnight scans from the Dudley hospital.

Mr Green had collapsed outside of The Three Crowns pub, in High Street, Brierley Hill, two days before.

Senior Coroner Zafar Siddique concluded a narrative verdict and did not rule neglect.

Mr Green was on Warfarin medication to thin his blood due to an existing heart condition, but it wasn't until after the second scan that drugs were given to reverse the effects of Warfarin when the bleed on the brain was detected, the court heard.

Joanne Taylor, lead consultant at the Dudley Group, said: "He was seen at 1.15am and a CT scan was ordered. The report showed no evidence of any bleed.

"Had we known of the first bleed we would of reversed the effect of Warfarin. Our practice would have been different had we had known there was a bleed."

The following morning a doctor noted a change in Mr Green's condition and upon looking at the scan he noted 'subtle evidence of a bleed'.

A second scan was completed at 11.30am, when an 'extensive bleed' was detected and the Warfarin reversed.

In a statement read out in the court from the radiologist who had interpreted the scan, it stated that the bleed had been 'overlooked' and that it had been an 'extremely busy evening'.

Doctor Martin Rimmer, clinical director at Radiology Reporting Online (RRO) - where the scan was sent, insisted that learning processes had been put in place across the whole company to ensure that a similar incident would not occur again.

However, in a follow up blind test of the first scan with other radiologist's - 60 per cent did not notice the bleed.

Coroner Zafar Siddique concluded a narrative verdict that Mr Green died from a bleed on the brain.

"Given the evidence that I have heard and this being a very experienced radiologist and that six out of 10 others did not spot the bleed then I will not make a formal finding of neglect," he said.

Mr Green's daughter, Zoe Green, described him as the 'life and soul of the party' adding that he was known by a lot of people who enjoyed being around him.