The death of a retired police officer whose head became trapped between the rails and mattress of his hospital bed was an "avoidable accident", a coroner has concluded. Max Dingle, 83, from Powys, died 15 minutes after he was found "entrapped" on a ward at the Royal Shrewsbury Hospital on May 3, 2020.
Concluding an inquest into Surrey-born Mr Dingle's death, a senior coroner found resuscitation had not been attempted despite the pensioner electing for life-saving intervention and having a pulse when he was found. Earlier this month, Shrewsbury and Telford Hospital NHS Trust, which runs the hospital, was fined £1,333,334 for failing to provide safe care to Mr Dingle and another patient - whose case is not linked - who died in different circumstances.
Senior coroner John Ellery said Mr Dingle, of Newtown, was originally admitted to hospital with "shortness of breath" on April 27, 2020. His medical history showed he had suffered with a heart condition, lymphoedema and sleep apnoea.
Read more: Welsh patient died after getting head trapped between bed rails and mattress in hospital
The coroner said: "He remained in hospital until May 3, at 10am, when he was found with his head trapped between the rails and mattress of his hospital bed. He suffered a cardiac arrest - from which resuscitation was not attempted - and he died at 10.15am."
Nobody from the hospital trust was present for the hearing but family members, including Mr Dingle's son Phil, dialled in from Australia. Mr Ellery said an initial post-mortem examination gave a cause of death of heart disease "and did not consider the entrapment caused or contributed to the death".
However, Mr Dingle's son "did not accept" those findings, instead commissioning expert consultant forensic pathologist Johan Duflou, from the University of Sydney, to review the findings and post-mortem examination. Prof Duflou gave a cause of death of "entrapment with positional asphyxiation".
After comparing and discussing their findings, both pathologists then agreed "entrapment did play a significant part in the cause of death", Mr Ellery said. An inquest was opened and adjourned while separate criminal proceedings against the NHS trust were carried out by health watchdog the Care Quality Commission (CQC).
The criminal inquiry ended this month after the trust admitted failings in connection with the care of two patients, including Mr Dingle. Concluding the inquest, Mr Ellery said: "Based on all the evidence, the conclusions of this inquest are Mr Dingle's death was an avoidable accident."
At Telford Magistrates' Court on May 18, a judge imposed an £800,000 fine on one of two charges relating to the death of dialysis patient Mohammed Ismael Zaman, 31. He also fined the Shrewsbury trust £533,334 over a charge brought in relation to Mr Dingle's death.
The judge acknowledged the fines were mitigated by the trust carrying out "full and extensive investigations immediately after both incidents". The trust, which was recently the subject of a highly-critical report into maternity services it offered between 2000 and 2019, admitted the charges through its barrister.
Separately, an independent review of maternity services, chaired by Donna Ockenden and published in March, found "repeated errors in care" at the trust, which led to injury to either mothers or their babies. Some 201 babies could have - or would have - survived had the trust provided better care, the report said.
