Kapi-Mana News - - NEWS -

re­mained in pain and could barely move, and slept one night in a chair, the re­port said.

Two days af­ter the fall, when Wilmshurst’s fam­ily gath­ered for his 62nd birth­day, he re­turned from the bath­room pale and breath­ing quickly, so the fam­ily called an am­bu­lance.

Be­fore the am­bu­lance and fire crews ar­rived, the fam­ily needed to start CPR, but he died.

Charles Free­man, giv­ing in­de­pen­dent ad­vice to the in­quest, said a doc­tor at the cen­tre ‘‘ se­ri­ously un­der­es­ti­mated’’ Wilmshurst’s in­juries, which were found in an au­topsy to be a col­lapsed lung, bleed­ing in the chest, and eight frac­tured ribs – most of them likely to have been caused in the fall rather than CPR two days later.

‘‘The rib frac­tures were found to be mul­ti­ple with some pen­e­trat­ing the chest cav­ity,’’ he said.

‘‘ This would have been the cause of the bleed­ing into the chest cav­ity and with his lung col­laps­ing, which can oc­cur some hours or days af­ter the orig­i­nal in­jury.’’

These is­sues could lead to heart at­tacks, he said.

In his find­ing, Smith said Wilmshurst died on De­cem­ber 28 from ac­ci­den­tally sus­tain­ing a blunt force chest in­jury, but also pointed to fail­ings by the cen­tre.

In a sep­a­rate re­view of the case, the Health and Disability Com­mis­sioner had rec­om­mended that triage and doc­u­men­ta­tion at the cen­tre needed to be im­proved.

‘‘I echo these sen­ti­ments and I ac­cept that [the cen­tre] has taken steps to rec­tify that, but I do be­lieve it needs to go fur­ther,’’ the coroner said.

He agreed with Free­man that Wilmshurst’s pulse and re­s­pi­ra­tory rate should have been recorded when he vis­ited the cen­tre, that not enough time was taken to look into what hap­pened when he fell, and that a chest X-ray should have been taken.

The cen­tre needed bet­ter sig­nage to say it was an ac­ci­dent and med­i­cal cen­tre, not an emer­gency depart­ment, Smith said.

A health board spokes­woman said ear­lier rec­om­men­da­tions by the Health and Disability Com­mis­sioner had been im­ple­mented.

The com­mis­sioner’s re­port said nurs­ing triage and doc­u­men­ta­tion for pa­tients in sim­i­lar sit­u­a­tions to Wilmshurst’s needed to be im­prove.

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