Richard HEDGES · Prevention of Future Deaths report

On 6 October 2023 I commenced an investigation into the death of Richard HEDGES. The investigation concluded at the end of the inquest . The conclusion of the inquest was

Accident

1a Hypoxic Brain Injury

1b Out of Hospital Cardiac Arrest

1c Fall with Traumatic Cervical Spine Fracture

II Chronic Obstructive Pulmonary Disease, Previous Pulmonary Embolism

Mr Hedges was admitted to the critical care unit following an unwitnessed fall at his residence.

He fell in some short stairs leading to a bin, and was found at the bottom of the stairs with his head down, already looking hypoxic was unresponsive, and a pulse was not detectable.
Immediate cardio-pulmonary resuscitation (CPR) was started by a grand-daughter.
London Ambulance service arrived and confirmed PEA arrest; further 22 minutes of CPR to obtain ROSC.
An iGel was inserted for ventilation.
Initially Mr Hedges was very unstable, requiring Adrenaline infusion to maintain blood pressure.
On arrival to A&E Mr Hedges was intubated and ventilated.
Trauma CT scan revealed an unstable C6 and C7 fracture and bilateral rib fractures (no flail segment).The spine was immobilized and the fracture managed conservatively.
The initial CT head showed no signs of intracranial injury except for a superficial haematoma on the scalp.
A superficial laceration was sutured in A&E.
Mr Hedges was admitted to critical care and stabilised.
He was neuro-protected for 48 hours, with full sedation.
Initial haemodynamic instability resolved, and he was almost off Noradrenaline.
Sedation (Propofol and Fentanyl) was stopped on 24/09 in the morning, but Mr Hedges remained with a GCS E1VtM1, and absent reflexes on triggering of the ventilator.
A repeat head CT head was done at 72 hours of admission; this revealed widespread hypoxic brain damage with bilateral uncal herniation, crowding of the foramen magnum, and bilateral extensive infarcts.
The overall outcome looked very poor given the prolonged out of hospital cardiac arrest, extensive hypoxic brain injury with uncal herniation and no improvement in neurology.
A decision was made to move to comfort care and extubate Mr Hedges, after discussions with the family members. The family mentioned multiple times that Mr Hedges had been deteriorating over the last 6 months prior to admission.
He was having memory problems, and had some panic attacks (long-standing problems).
Mr Hedges sadly passed away on 26/09/23 @ 15:48

(1)The short external staircase where Mr Hedges fell is constructed of concrete steps which are showing signs of wear/weathering. The steps are not coated with a non slip surface and the edges of the steps do not have highlighting to increase awareness.

(2)The handrail for use with the steps appears too short at each end and reduces the available support to users of the steps

(3) The current lighting of the area of the external staircase is poor.