William Leonard Beckwith · Prevention of Future Deaths report

On18th October 2013 I commenced an investigation into the death of William Leonard Beckwith, 91 years old. The investigation concluded at the end of the inquest on 10th April 2014. The conclusion of the inquest was one of Accidental Death.

The medical Cause of Death being:

1a. Gastro-intestinal tract haemorrhage.
1b. Duodenal Ulcer

II. Cervical spine fracture (treated), Acute stress ulceration, Bronchopneumonia

On the 13th September 2013 William Leonard Beckwith sustained a fracture to his cervical spine resulting from a fall at home. He attended the accident and emergency department of the Chesterfield Royal Hospital. Medical and Nursing staff were aware of a history of previous falls. Reduced range of movement of his cervical spine was noted at that time, however his fracture was not diagnosed and he was discharged home at 04:17 hours in the morning. He was readmitted with acute stridor on the 15th September 2013 caused by a blood clot from the cervical fracture compressing his wind pipe. Despite management in intensive care and on the ward he continued to deteriorate and died on the 11th October 2013. From the evidence heard at inquest, on the balance of probabilities, earlier diagnosis of the fracture would not have affected the outcome.

A 91 year old patient, with a history of falls and who had attended A&E due to a fall was discharged home at 04:17 hours in the early morning to his elderly wife. There was no formal assessment as to his abilities, the home environment or his wife’s abilities to look after him. No consideration was given to post discharge planning or assessment of needs such as district nurse or social care follow up. The Department, at that time, did not have in place any formal policy or procedure for risk assessing the safety of discharging a frail, elderly patient to home in the early hours of the morning.