The death of an elderly man has sparked concerns around systems at a Doncaster hospital.
Roy Burgess, aged 87, fell in his garden and broke his hip back in December 2017.
A report said Mr Burgess was taken to Bassetlaw Hospital in Worksop but was then transferred to Doncaster Royal Infirmary for surgery.
South Yorkshire East District assistant coroner Sarah Slater said post operation there were ‘missed opportunities’ to identify and escalate Mr Burgess’s deteriorating condition prior to his death.
The inquest concluded in November 2018 but the coroner's report was published this week.
But she added it was ‘unlikely’ that ‘any such interventions would have altered the outcome’. It was also found Mr Burgess had heart disease.
The coroner said the hospital's ‘Early Warning System’ used to identify a deteriorating patient was ‘not adhered to’ and there was ‘inadequate record keeping’ within the clinical notes.
The report went to say Mr Burgess’s care was escalated five time in less than five hours on Dec 4, 2017 but no entries were placed in his clinical records.
The coroner also found that ‘untimed, dictated notes’ of ward rounds were then entered into the records in a ‘non-chronological order’, which was said to be ‘unhelpful and potentially misleading’.
Mrs Slater sent her findings to Doncaster & Bassetlaw Teaching Hospitals chief executive Richard Parker and Health Secretary Matt Hancock, which said: “There were numerous examples having been escalated by nursing staff to doctors but no record of their input following this escalation was entered into the notes.
“This could have had a detrimental impact on his care and if this practice continues, it will potentially affect other patients.
“During the course of the inquest, the evidence revealed matters giving rise to concern.
“In my opinion, future deaths will occur unless action is taken and I believe you have the power to take such action.”
Mr Sewa Singh, medical director at Doncaster and Bassetlaw Teaching Hospitals, said: “On behalf of the Trust, I would like to once again express my deepest condolences to Mr Burgess’ family and apologise for any shortcomings in the care and treatment offered to Roy shortly before his passing.
“As a Trust, we have taken the opportunity to learn and improve our practices, and as such we will be implementing improved and role-specific training regarding our Early Warning System, as well as reinforcing good record keeping amongst clinicians at all times. “