Peter Norman Nott · Prevention of Future Deaths report

On 9 September 2013 an investigation commenced into the death of Peter Norman Nott, who was 75 years old. The investigation concluded at the end of the inquest on 26 February 2014. A short form conclusion of accidental death was recorded. Dr Norman Nott had fallen in his room at Rush Court Nursing Home causing injury to his head. The fall occurred around 10:30 hours but he was not taken to the hospital until 18:57 hours that evening. He succumbed on 8 September 2013. The medical cause of death was recorded as:

1(a) Subdural haemorrhage
1(b) Parkinson's disease

1. Dr Peter Norman Nott had a complex medical history of Parkinson's decease with Shy-Drager syndrome (severe postural hypertension) with Dementia. He was assessed as being at very high risk of falls.

2. Although the nursing home had undertaken detailed assessments to address Dr Norman Nott’s propensity for falling, there were numerous incidents of falls at the home.

3. As indicated, on the morning of 2 September 2013 Dr Norman Nott experienced an unwitnessed fall in his room at the nursing home. He was attended by nursing home staff and was conscious. He spent the next two hours lying down (which was not uncommon) until he was hoisted onto the bed where he remained and was nursed and regularly checked. Also the GP was called and suggested that he be closely monitored.

4. At 17:45 hours his condition deteriorated and an ambulance was called which took him to hospital at 18:57 hours

5. The hospital took a CT scan and in view of his condition considered that surgical intervention was futile.

6. He sadly passed away on 8 September 2013 at 20:00 hours.

1. Although staff at the care home were attentive to Dr Norman Nott after his fall, and advice was sought from Dr Norman Nott’s GP, it was accepted in questioning that the trained staff should have undertaken neurological observations over and above a simple visual examination.

The need to undertake further examination was heightened when the length of time Dr Norman Nott remained lying down (although conscious) and certainly as this time extended into the afternoon.

I recommend that Rush Court Nursing Home review their procedures for attending on a patient after a fall (whether conscious or not) in order to identify the appropriate level of examination and nursing attention required.

2. When Dr Norman Nott arrived at hospital the Emergency department undertook a CT scan and the evidence from the Consultant Geratologist and Acute Physician was that due to the degree of brain injury and the fact that Dr Norman Nott had been “deeply unconscious from the beginning” earlier attendance at hospital would have not made any difference to the outcome.

The doctor’s conclusion that Dr Norman Nott had been unconscious was information obtained from the paramedics attending at the nursing home who had gleaned the information that he was unconscious from the staff. The evidence that Dr Norman Nott was unconscious was incorrect. This information should have been passed on accurately.

My recommendation is that the Rush Court Nursing Home review the information they provide to paramedics attending and the procedures in place to ensure the accuracy of the information can be passed to paramedical staff attending at the home.