Laura Hill · Prevention of Future Deaths report

On the 9th October 2013 I commenced an investigation into the death of Laura Hill date of birth 13.09.1936. The investigation was concluded at the end of the Inquest on the 5th February 2014. The conclusion of the Inquest was that the deceased had died as a result of 1a) Pneumonia 2) Chronic Obstructive Pulmonary Disease, Ascending Cholangitis, dislocated left hip replacement requiring manipulation, Vascular Dementia, Rheumatoid Arthritis and immunosuppression treatment. I returned a conclusion that she had died as a result of natural causes.

On the 28th September 2013 the deceased presented to Stepping Hill Hospital with acute abdominal pain and sepsis due to cholangitis. She had an extensive complex medical history. She was admitted for treatment initially to the Surgical Assessment Unit. She was initially treated with antibiotics and was not considered fit enough to undergo MRCP procedure.

On the 1st October the deceased was transferred to ward B6. At 03.50am on the 2nd October the deceased was seen to fall from her bed, as a result she sustained a fracture to her left hip. This required manipulation and needed several attempts before this was successful.

The deceased continued to deteriorate and died on the 8th October 2013. The death was initially reported to the Coroner's Office with a cause of death offered as 1a) Pneumonia and 1b) Manipulation under anaesthesia for displacement of left total hip replacement. At the inquest I heard evidence that the pneumonia was on balance due to her admitting condition and a number of co-morbidities.

However I also heard evidence that on her admission to hospital no Falls Risk Assessment was carried out, that she was transferred between wards at 01.30am and that on arrival on Ward B6 where she had her fall there was again no Falls Risk Assessment carried out. It was noted that the deceased would in all likelihood have been assessed as requiring cot sides (albeit that does not prevent someone falling) and identified as at high risk of falls.

Despite training being in existence in relation to the carrying out of Falls Risk Assessments there was a missed opportunity throughout the time Mrs Hill was in hospital for this to be carried out. There was no assessment on her admission to Ward C3 nor when she was transferred to Ward B6.