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Friday 6 September 2019 The Guardian •
National^15
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.▲ Sarah-Jayne Roche, who halted in
agony while running with husband,
Steven PHOTOGRAPH: ATHENA PICTURESCoroner says doctors’
‘gross failure’ to diagnose
broken leg led to death
Steven Morris and agency
A runner whose broken leg sustained
during a half marathon was misdiag-
nosed as a pulled hamstring died after
“gross failings and neglect”, a coroner
has concluded.
Sarah-Jayne Roche, 39, a mother
of two, died as she was operated on
12 days after she collapsed during the
Cardiff half marathon. She attended
hospital three times before the broken
femur was diagnosed and died after
she developed deep vein thrombosis.
The coroner, Graeme Hughes, said
there were three “red fl ag opportuni-
ties” missed to x-ray Roche – leading
to a “gross failure”. Hughes found that
had there been an x-ray, the operation
would have taken place a week earlier.
The inquest heard that Roche, from
Beddau near Pontypridd, was running
last 7 October to raise money for a Par-
kinson’s charity after her father, Alan,
was diagnosed with the disease.
At the seven-mile point with her
husband, Steven, 42, she felt “a shoot-
ing pain up her leg” and came to a halt.
She visited hospital on three occasions
where she was given painkillers and
told to apply ice. Hughes said: “I am
satisfi ed, had she been x-rayed on
October 7, 8 or 12, on the balance of
probabilities she would have survived
and not died on October 19.”
The coroner said there was a failure
in Roche’s care when all three hospi-
tal appointments were “considered
cumulatively”. He said: “They do
amount to a suffi cient level of fault.
There were three ... red fl ag opportu-
nities to procure an x-ray.” He added
there was a “serious underestimation”
of her condition.
Giving a narrative conclusion,
Hughes said: “Whilst undergoing
surgery to fi x a fractured femur at
the Royal Glamorgan hospital, Sarah-
Jayne Roche developed pulmonary
thromboembolism as a consequence
of an undetected and undiagnosed
deep vein thrombosis. She went intois untrue, I remember feeling the knee,
thigh and hamstring and pulling on
the lower leg.” Manfi eld also told the
inquest that he had ordered an ultra-
sound scan, but the paperwork was
never found.
The inquest heard that school
worker Roche had set running the half
marathon as a challenge to complete
before she was 40.
Kamal Asaad, the medical director
at Cwm Taf Morgannwg University
Health Board , said: “We are deeply
sorry about Sarah-Jayne’s death and
would like to off er a sincere and unre-
served apology to her family and
friends for the failings in her care.
“Words are of little comfort at this
distressing time but we would like to
assure the family that changes have
already been made to help prevent
such failures in the system from hap-
pening in the future.
“A full investigation into the care
she received was instigated imme-
diately, and actions are being taken
and closely monitored to address the
shortcomings that were identifi ed.
These include strengthening our
clinical processes,including x-ray
procedures in A&E, as well as our pro-
tocols for more detailed assessments
and investigations before reaching a
defi nitive diagnosis.
“We accept the coroner’s ruling
and will now review all of his fi nd-
ings to ensure we fully address all of
the failings.”‘There were
three ... red fl ag
opportunities to
procure an x-ray’Graeme Hughes
Coronercardiac arrest and despite extensive
resuscitation attempts died at 7pm
that evening.”
He added there was a “gross failure
on the part of clinicians” to develop
correct diagnoses – contributing to
the development of DVT, pulmonary
thromboembolism and her death.
The coroner said there was “con-
flicting” evidence from Dr Tim
Manfi eld, who saw Roche on 12 Octo-
ber , and her mother, Patricia Newman.
Newman claimed the doctor did not
physically examine her daughter’s
leg despite being told it was “freezing
cold”. Manfi eld told the inquest: “ThatRELEASED BY "What's News" vk.com/wsnws TELEGRAM: t.me/whatsnws