Derek Wynne Turnbull · Prevention of Future Deaths report

On 10th August 2016 Mr Derek Wynne Turnbull aged 86 years died at Sunderland Royal Hospital.
I concluded the Inquest as part of my investigation on 15th March 2017 recording a conclusion of an Accident. The Cause of Death following Post-Mortem Examination was: -
I a Bilateral Bronchopneumonia;
Contributed to by
II Congestive Cardiac Failure; Ischaemic Heart Disease and Hypertensive Heart Disease; Right Subdural Haematoma consequent upon a fall

Mr Derek Wynne Turnbull had been a resident at the ICAR Unit since 1st August and he had a recognised risk of falls. He was on Warfarin.

On 9th August 2016 Mr Turnbull was seen by a member of staff at 02:30am. Staff were alerted by an alarm in Mr Turnbull’s room that he was mobile at 03:15am and discovered him face down on the floor. His fall was not witnessed. Staff attended to Mr Turnbull’s facial injuries and, although he was observed, an ambulance was not requested to take him to hospital until 04:18am.

Paramedics attended to Mr Turnbull at 04:35am and transported him to Sunderland Royal Hospital Emergency Department by 05:24am.

Mr Turnbull had a CT Scan at 05:48am, and at 07:19am he was given Beriplex to reverse the effects of Warfarin.

Mr Turnbull had a large acute-on-chronic subdural haemorrhage and surgical intervention was not an option. Mr Turnbull was made comfortable and passed away on 10th August 2016 at 08:15pm.

Mr Derek Wynne Turnbull had a known history of falls, was on Warfarin and had sustained an obvious head injury after an unwitnessed fall, yet it took from 03:15am to 04:18am to summons an ambulance by a 999 call in a case that was to be “stepped up” to hospital in any event. There was no purpose in waiting, given the known scenario.

In Mr Turnbull’s case the delay may not have caused or contributed to his death, but in other cases the opportunity for earlier review at the hospital ought to be taken.

Policies, procedures and protocols may need to be reviewed in order to ensure that in those cases that are to be stepped up, that the action is taken immediately.