A hospital failed to spot an 86-year-old woman had a broken neck following a fall at a nursing home, a review has revealed.
The woman, referred to as Mrs Webster in the Northamptonshire Safeguarding Adults Review, was admitted to Kettering General Hospital in 2017.
She was transferred to another hospital but the correct CT scans were not passed on so the break was missed.
She was later re-admitted to Kettering hospital where she died.
Kettering General Hospital has apologised.
Mrs Webster, who had a history of falls, was taken to Kettering hospital on 10 November 2017 after falling and cutting her face, according the Local Democracy Report Service.
CT scans were carried out on her back and head and she was transferred to Northampton General Hospital for specialist treatment for her facial injuries.
However, the correct scans were not transferred with her, so she was discharged.
She was re-admitted to Kettering when her GP reviewed her scans and spotted the break in her spine. She died on 28 November after her condition deteriorated.
A post-mortem examination found her death was as a result of bronchopneumonia, “likely exacerbated by lack of mobility due to the neck collar worn”, the review said.
She was placed in a neck brace when she was readmitted to hospital which the review said was “standard medical practice to stabilise the injured area”.
The review said an inquest was not held because it was “deemed to be a death by natural causes”. It added it was “statistically predictable that Mrs Webster would die following a fall”.
Kettering General Hospital’s director of nursing, Leanne Hackshall, said: “We would like to apologise to Mrs Webster’s family for aspects of her care including our failure to diagnose a spinal fracture and to pass on the most recent CT scans to Northampton General Hospital.
“While the review found that – given Mrs Webster’s advanced age and many medical problems, including severe osteoporosis – that her treatment would have been unaffected by this error, we do deeply regret that it occurred.”
Both the review and the hospital’s internal review recommended Kettering hospital develop an emergency transfer document for use in the emergency department, which it said had since been carried out.