AN elderly woman who was sent home from hospital with a missed fracture later died on the operating table from a rare complication, an inquest heard.

Joan Betteridge from Chandler’s Ford suffered a hip injury following a fall but this was not picked up during an x-ray at Royal Hampshire County Hospital in Winchester.

It was eventually discovered during another hospital admission, but during later hip replacement surgery she had a severe reaction to the bone cement used in the operation.

Winchester Coroner’s Court heard that the missed fracture did not affect the overall outcome, as the cause of Mrs Betteridge’s death was Bone Cement Implantation Syndrome - a condition with varying degrees of severity that results in fatalities in less than 0.5% of cases.

Although the condition is not fully understood, it is thought that one serious but rare reaction to the bone cement is that bone marrow is displaced and enters the blood vessels.

Orthopaedic surgeon Hugh Fox told the court that the operation that took place on June 10 would have been identical to the one that would have taken place if the fracture had been discovered earlier.

He added that the syndrome caused Mrs Betteridge’s heart to slow down, and later a cardiac arrest.

Consultant anaesthetist Dr Philip Dodd said since the death, Hampshire Hospitals NHS Foundation Trust had taken steps to formalise what is known as the “Coventry Curfew”, which outlines the responsibilities of theatre staff when bone cement is used, although this was already being used in practice before the incident.

The 88-year-old was living at Brendoncare Knightwood Court Care Home with Peter, her husband of 67 years, at the time of her death.

Her mobility was affected by her Parkinson’s disease, and following a fall on May 31 she was sent home from hospital despite being unable to bear weight on either leg, because two doctors did not spot the fracture.

It was also heard that a follow-up report on the x-ray within 48 hours, which was supposed to act as a safety net to prevent breaks being missed, was not received until June 12 - two days after her death.

Mrs Betteridge was temporarily transferred to the Old Parsonage in Otterbourne for nursing care where her physiotherapist Matthew Rhode remained concerned about the amount of pain she was in.

Debbie Harwood, her daughter, said: “Staff at Brendoncare expressed surprise that Joan had been sent home from hospital. She had been advised to keep mobile but she was in so much pain it was virtually impossible.The hospital seemed desperate to send her home instead of getting to the bottom of why she was in so much pain.”

At the time of going to press, the inquest was still ongoing.