Martha Ann Davies · Prevention of Future Deaths report

On 16 May 2016 I reopened the inquest touching upon the death of Martha Ann Davies. The cause of death was 1a) subdural haematoma 1b) multifactorial fall 1l) fracture neck of femur (treated)

The jury’s conclusion at the end of the inquest was a narrative conclusion:- Martha Ann Davies died as a result of an accident. We agree that Mrs Martha Ann Davies was given adequate and appropriate care at Colchester Hospital University Foundation Trust, that Mrs Martha Ann Davies did not receive adequate care and appropriate treatment at Clacton District Hospital and that this may have contributed to her death

The deceased, a very fit 98 year old lady, fell at home and was admitted to Colchester Hospital on 11 October 2015 where she received surgery for a fractured hip. On 7 November she was then transferred to Clacton Hospital for rehabilitation. On 17 November she suffered a fall and she was transferred to Colchester Hospital on 19 November. She died there on 29 November.

(1) Serious failings in communication between shifts, with senior staff, and at multi-disciplinary meetings
(2) Over reliance upon agency staff and on junior staff to make decisions
(3) Lack of prompt response to the patient’s deteriorating state.
(4) Lack of engagement of ward staff and ward manager
(5) Failings in the documentation