TWO senior hospital staff failed to spot a pensioner's brain haemorrhage on a scan when she went to A&E, an inquest has heard.

Assistant Bradford coroner Oliver Longstaff said had Anneliese Loughlin's condition been diagnosed the day she went to Bradford Royal Infirmary (BRI), doctors would possibly have reversed the blood-thinning warfarin drug she was taking, meaning it might not have got worse.

He said if that had happened, the 82-year-old would not have died when she she did.

Instead, Mrs Loughlin, from Summerbridge Drive, Eccleshill, was sent home after a radiologist and a consultant , who both looked at her head scan results, missed the small bleed she suffered in a fall at home on May 16 last year.

She was re-admitted to the BRI a few days later after deteriorating and a second head scan revealed a large bleed.

The original scan was then checked again and tiny spots of blood were noticed at the back of her brain - not the usual presentation of a haemorrhage caused by a fall, Bradford Coroner's Court heard yesterday.

Radiologist Dr Amir Iftikhar told MrsLoughlin's family in court the bleed should not have been missed.

Consultant Dr Louise Hatton also said sorry, but pointed out the bleed was tiny at that stage and had only been visible on five out of 200 images taken.

However, the inquest did hear nine out of ten doctors who later looked at the same images as part of a learning exercise did spot the bleed on the very first scan.

Mrs Loughlin's eventual death at BRI on July 7 was investigated by a serious incident review and as a result changes have now been made to the hospital's head injury care procedures.

All head injury patients on blood-thinning drugs are tested to see how much is in their system in case it needs reducing and patients with a significant risk of bleeding - regardless of what scans show up - will always be kept in hospital, unless a senior A&E doctor agrees it is safe to go home.

Mr Longstaff said he would be considering whether the changes at BRI could be forwarded to NICE (the National Institute for Health and Excellence) to be included in its national head injury guidelines.

"The bleed was an unusual presentation but was discernible from the first CT scan. On the narrowest of possibilities, had her warfarin been reduced on May 16 Mrs Loughlin would not have died when she did," he said.

Speaking directly to the family, he added: "Many families come here hoping the loss visited on them will not be visited on others. I hope what you have heard about changes at the BRI and what may be made to NICE will give you some comfort and confidence."

Mr Longstaff recorded the death as misadventure.