Leslie Douglas Murray · Prevention of Future Deaths report

On the 30th day of July 2015 I opened an investigation touching the death of Leslie Douglas Murray, who died aged 89 years on the 28th July 2015 in St George’s Hospital

The inquest was concluded on the 13th January 2016 at Westminster Coroner’s Court.

The medical cause of death was recorded as:

1(a) Bronchopneumonia.
(b) Acute Subdural Haemorrhage and Cervical Spine Fracture.
(c) Fall

2 Chronic Obstructive Pulmonary Disease and Hypertension.

How, when and where and in what circumstances the deceased came by his death:

On the 24/7/2015, Mr Murray fell down stairs sustaining injuries including spinal injuries at home. He was admitted to Frimley Park and then St Georges Hospital. He was assessed as requiring 1:1 nursing care, but cover was not available. On 27/7/2015 he fell from his bed sustaining further injuries that led to and caused his death. If the extra cover had been in place to provide him with 1:1 care, this fall would have been prevented. He died on 28th July 2015

Conclusion of the Coroner as to the death:

Accident

Evidence taken at the inquest was that there were three such patients requiring 1:1 on 27/7/2015, but only one extra HCA to provide that cover. This meant that there was down 2 HCAs at the material time. I was satisfied that the nurses had done all that they could to request cover and had positioned these patients close to the nursing station and together to try and observe them closely. Mr Murray fell when the HCA and nurse were attending another patient close by.

I was satisfied on the balance of probabilities that if there had been the appropriate number of staff on duty such that Mr Murray had not been left unattended then simple reassurance would have been enough to prevent him from trying to climb off bed when he awoke disorientated, as this had always been sufficient in the past. The head injury he sustained worsened his clinical condition and thus contributed to his death, which occurred the day after the hospital fall.

The court also heard that such situations were no cover is provided for patients requiring 1:1 care occurs frequently on the ward where Mr Murray was being cared for at the time of the fall.

(1) That insufficient cover is provided to allow 1:1 care to be given to patients that require it on this ward (Holdsworth) and likely others throughout the hospital, and as such patients are suffering preventable falls that may be causing fatal injury, or suffering other care deficiencies that may cause or contribute to death.