Kenneth William Horne · Prevention of Future Deaths report

On 23rd March 2018 I commenced an investigation into the death of Kenneth William Horne. The investigation concluded at the end of the inquest on 2nd May 2018. The conclusion of the inquest was that the deceased had a history of lung cancer in 2015 which had been operated on. In December 2016 he was admitted to the Royal Stoke University Hospital, Stoke on Trent with a chest infection. He was investigated for cancer of the colon but was unfit for further tests due to his comorbidities and general frailty. He transferred to ward 80 where infections settled. He suffered two falls on the ward whilst mobilising from the toilet without requesting assistance. One of the falls was on the morning of the 27th January 2017 which was also his planned discharge to Leek Moorlands Hospital where he was admitted at 7.50pm. Details of his previous falls were not included on the discharge letter and there was no verbal nurse to nurse handover. His falls documentation and risk assessments were sent with him to Leek Hospital but the transfer of care form had not been updated. At 2.00am on the 28th January 2017 he was found on the floor at the side of his bed. Observations indicated a deteriorating condition and he was readmitted to the Royal Stoke University Hospital. A CT scan found a very large haematoma of the left thoracic wall and possible infection. His nutritional intake remained poor. He was not suitable for intervention and was treated as palliative. He transferred to Bradwell Hall Nursing Home, Newcastle-under-Lyme on the 22nd February 2017 where he died on the 24th February 2017. The cause of death was
1a Sepsis.
1b Bronchopneumonia.
1c Chest wall injury.
II Old age.

The conclusion of the inquest was Accidental Death.

(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.