ONE of the region’s hospitals has changed its policy after accepting its mistake may have contributed to the death of a patient.

An inquest heard that Hartlepool man Brian Steels was taken to hospital in Stockton after falling off a ladder and banging his head.

He was seen by a junior doctor who sent him home after 30 minutes.

Retired engineer, husband and father, Mr Steels, who was 72, died two days later as a result of brain injuries he suffered in the fall.

The inquest heard that the trainee doctor should have consulted with a senior medic but had not.

The situation was made worse by the fact that Mr Steels was on blood thinning drugs, which should have led to more observation.

Hartlepool and North Tees NHS Foundation Trust has since changed its policy and a senior consultant is now in the accident and emergency department from 8am to 10pm and on call through the night.

Coroner Malcolm Donnelly told the inquest that he had sought and received assurances from the NHS that accident and emergency cover is adequate because, since Mr Steels’ death, it has been downgraded in Hartlepool.

Mr Donnelly recorded a narrative verdict that: “Mr Steels’ death was accidental though aggravated by failure to initiate timely and appropriate medical attention.”

The inquest heard that Mr Steels was up a ladder, his head about 10ft from the ground, fixing the garage roof when he stumbled.

His wife, Margaret, told the inquest: “I was standing at the bottom of the ladder when he fell. I tried to catch him, but his weight was too much and he fell through my arms. His head hit the refuse bin and then the concrete.”

He was taken to the University Hospital of North Tees, in Stockton, where he was seen by the junior doctor for 30 minutes.

Mr Steels was talking lucidly and said he did not have a headache and he was not vomiting.

Two days later, Mr Steels suffered bleeding to the brain and died at the University Hospital of Hartlepool.

Dr Anne Thistlethwaite, a consultant at the Stockton hospital, was at the inquest and said Mr Steels should have been kept in hospital for more observation, especially because he was taking, for other health reasons, Warfarin, a blood-thinning drug.

She said middle-grade doctors were and are present 24 hours a day and the junior doctor should have sought advice from one of them.

Mr Donnelly said: “There was no further help from the senior people available at the hospital. That’s what should have happened and it didn’t. I don’t think the trust is trying to hide anything and procedures and supervision seems to be tightened up a bit.”

After the inquest, Mr Steels’ widow declined to comment, but said she disagreed with the downgrade of Hartlepool hospital.

A spokesman for the trust said: “We extend our deepest sympathy to Mr Steels’ family.

This is clearly tragic but important lessons have been learnt and changes made.”