Mr John Thomas Lambton · Prevention of Future Deaths report

On 27th August 2017 Mr John Thomas Lambton, known as Tom, aged 88 years, died at Sunderland Royal Hospital. The Inquest, as part of my Investigation, concluded on 13th February 2018, when I recorded a conclusion of Accident.
The Cause of Death following Post-Mortem Examination was: -
Ia Brain Herniation
Ib Raised Intracranial Pressure
Ic Subdural Haematoma
II Dementia and Warfarin Therapy

Tom was admitted to Sunderland Royal Hospital on the 8th of August 2017 following a series of unwitnessed falls/incidents over several days whilst in respite care at Dairy Lane Care Centre. Subsequent radiological Investigations revealed he had sustained a fractured neck of femur (NOF) and had an active subdural haemorrhage. On the morning of Saturday the 5th of August Tom was noted to have a bump to his head. On the evening of Sunday the 6th of August Tom was noted to be asleep in his room. At 8.45 PM he was found lying on the floor between his bedroom and en suite bathroom. Tom was assisted back to his bed by care staff and he requested an ambulance. At lunch time on Monday the 7th of August the GP attended Dairy Lane and examined Tom. On Tuesday the 8th of August at 11.20AM Tom arrived to hospital by ambulance. Tom underwent surgical repair of his NOF fracture, which was uneventful, the subdural haemorrhage was managed conservatively with close monitoring and reversal of his warfarin anticoagulation. He appeared clinically stable for over a week, repeat scans showed no change in the size of the subdural haematoma and he was treated for a minor urinary tract infection and delirium. He deteriorated rapidly 18 days post admission with reducing conscious level and episodes of apnoea, attributed to a subdural re-bleed, and subsequently died on 27th August 2017.

(1) Care home staff with no formal medical training made assumptions about Tom’s health following a series of falls/incidents
(2) Care home staff disregarded Tom’s request for an ambulance following the fall
(3) There was insufficient communication with the GP about recent events concerning Tom