Doctors' failings at Croydon University Hospital not to blame for great-grandfather Desmond Dudley's death
Doctors who placed a 'do not resuscitate' notice on a great-grandfather's medical records but failed to tell his family were not to blame for his death, an inquest heard.
Desmond Dudley, 93, from Sanderstead, died in Croydon University Hospital in 2010 after suffering a heart attack.
Croydon Coroner's Court heard that the nurse who found him dying in his hospital bed did not attempt to save him as she knew the notice had been written in his records.
Mr Dudley, a retired sales representative, was admitted to hospital with fractured ribs on March 30 after falling down stairs in his Hyde Road home.
Neither Mr Dudley's wife Ellen or son Robert learned about the no resuscitation notice until his death five days later, despite them visiting him in hospital and NHS guidelines stating family should be told within 24 hours.
Coroner Roy Palmer criticised this failure at the close of the inquest on Tuesday February 12, and also branded nurses' note-taking - which meant that no medical records were available for two nights of Mr Dudley's time in hospital - inadequate.
He said: "The clinical record keeping was far from perfect. Indeed on the two nights when Mr Dudley was said to have been provided with one-to-one observation, there are no clinical records available of his condition.
"The absence of adequate clinical records all too often poses considerable difficulty in cases that fall for forensic consideration, and this is certainly one such case.
But he said the no resuscitation notice had "no causal relevance" to Mr Dudley's death and was satisfied that Croydon NHS Trust had changed its procedures to ensure the mistake was not repeated.
Dr Palmer added: "It is my view, on the balance of probability, that Mr Dudley’s deterioration and death was the consequence of his injuries, sustained in the fall that led to his admission to hospital."
He recorded a verdict of accidental death.