Hilda Florence Thompson · Prevention of Future Deaths report

On 30/1/14 I opened the inquest into the death of Hilda Florence Thompson, who at the date of her death was 101 years old. The inquest was resumed and concluded on 27/8/14
I found that the cause of death to be:

1a – Subdural Haemorrhage
1b – Head Injury
2 - Congestive Cardiac Failure

I concluded with a narrative conclusion as follows:

On 1/1/14 Hilda Florence Thompson who had a history of cardiac ill health and asthma was admitted to A&E at East Surrey Hospital with breathlessness, for which she was treated. Subsequently on 19/1/14 she suffered a witnessed collapse causing her to sustain a subdural haemorrhage to which she succumbed and died on 22/1/14.

Mrs Thompson who had limited mobility and a history of falls was admitted to A&E at East Surrey Hospital on 1/1/14 suffering with breathlessness, where she was treated for possible worsening heart failure and renal function. She was moved from the acute medical unit to Holmwood ward on 8/1/14 where she was identified as a high falls risk. On 19/1/14 she was seen in the corridor adjacent to her room calling for help and holding onto a chair, but had a collapse before the senior nurse could reach her, and she struck her head on the floor. CPR was immediately commenced and she was restored to consciousness. Subsequently a CT scan showed that she had suffered an extensive intracranial injury to which she succumbed and died on 22/1/14.

• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk.
• There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place.
• Poor note taking of 2/1/14 to account for this.
• This left a gap of some 10 days during which she was not properly risk assessed for falls.

I would ask that you consider giving further consideration to the procedures and systems to ensure that there is no further repetition.