Nellie Travis · Prevention of Future Deaths report

On 14th October 2013 I commenced an investigation into the death of Nellie Travis, date of birth 13th March 1927. The investigation concluded on the 28th February 2014 and the conclusion was Accidental Death. The medical cause of death was 1a Haemorrhagic cerebral infarction and 2 Pneumonia, fractured neck of femur sustained following a fall, chronic bronchitis and emphysema, idiopathic anaemia.

She was admitted to hospital for the problem of her anaemia. On the 2nd October 2013 she was rising from her bed in the hospital ward when she fell and broke her hip.

During the course of the evidence I was told that there is a Falls Risk Assessment tool used by the hospital, but in this case it had been completed and assessed by a ‘bank nurse’ who was not an employee of the Trust. The evidence given by the senior member of the nursing staff was to the effect that the operation of the Falls Risk Assessment Tool is very subjective and depends upon an individual opinion of the nurse completing it as to how high the falls risk is shown to be. It was agreed that such a document is of very little use at all and that a more objectively assessed tool needs to be adopted.