Ethel Cross · Prevention of Future Deaths report

On 22nd April 2013 an investigation commenced into the death of Ethel Cross, aged 91 years. The investigation concluded at the end of the inquest on 22nd October 2013.

The record of the inquest confirmed as follows:

The Medical cause of death was
Ia Fat Embolism
Ib Fractured Neck of Femur

II Chronic Heart Failure and Coronary Heart Disease

The conclusion of the Coroner as to the death was
Accidental Death

Ethel Cross had a history of falls.
On 12th April 2013 at 0630 hours who had a history of falls, fell whilst returning from the bathroom on ward 4 at the Clifton Hospital. She sat on a chair for a rest. The chair slipped. She suffered a fracture to her neck of femur. Initially, she was not noted to be in pain. She later did complain of pain and was therefore taken to Blackpool Victoria Hospital.
She died on the 13th April 2013.

During the Inquiry, I received evidence that chairs utilised by staff which have wheels attached to them had been present on ward 4 and that Ethel Cross had sat on one of these chairs which slipped and she suffered a fracture. I heard evidence that these chairs have been removed from two wards – including ward 4 - on which elderly patients at significant risk of falls may be cared for. I am concerned that such chairs may continue to be present on other wards within the Trust where such patients may have access to them and similar incidents may occur.

During the course of the evidence I heard that although at high risk of falls, and someone who would need one to one assistance from staff when mobilising, Ethel Cross was not provided with an alarm that in the event of her moving when staff are not nearby could alert members of the medical staff to such movement allowing the staff to attend to her. All such alarms on the ward were in use and such alarms are rarely not deployed.

Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:

• the presence of such chairs - with wheels attached – in an area frequented by elderly patients may lead to further such fatalities should elderly patients access them

• patients who are at high risk of falls may try to mobilise themselves unsupported when staff are busy elsewhere on the ward with other patients and all of the available alarms are in use.

I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any the Trust proposes to take to address these two areas of concern.