Mary Jones · Prevention of Future Deaths report

On 5ᵗʰ March 2019 I commenced an investigation into the death of Mary Jones. The investigation concluded on the 23ʳᵈ August 2019 and the conclusion was one of Narrative: Died from the recognised complications of an accidental fall in combination with underlying frailty.

The medical cause of death was 1a) Hospital acquired pneumonia on a background of congestive cardiac failure and acute kidney injury ; 2) Left fractured neck of femur (operated on), Frailty

Mary Jones had an accidental unwitnessed fall. She was admitted to the Manchester Royal Infirmary (MRI) where she was operated on. She was transferred to Trafford General Hospital for rehabilitation. She was increasingly confused post-admission, probably due to dehydration and pain. On 3ʳᵈ March 2019 she deteriorated rapidly having acquired an acute pneumonia on a background of congestive heart failure and acute kidney injury which in combination led to her death on 3ʳᵈ March 2019 at Trafford General Hospital.

1. Mary Jones was a frail elderly lady who was moved from the MRI to Trafford General post-operatively for rehabilitation under the Trust structure. It was a planned transfer. However due to limited transport availability she arrived at Trafford General out of hours after waiting for transfer. As a result she was clerked in and risk assessed out of hours despite the recognised risks of moving frail elderly patients out of hours. The inquest was told that this is not uncommon as transfers such as these are made via ambulance and are a low priority and moved where needed;
2. The falls risk assessment was completed outside the Trust target time primarily as a result of the late arrival;
3. The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs Jones;
4. The documentation issue was exacerbated by the Trust IT merger having resulted in the loss of a number of key documents. It was unclear how the Trust were managing the risks around lost medical records where the IT merger was at the root of the issue;
5. Despite her frailty there was no evidence available at the inquest of a referral to a dietician/nutritionist. There was to have been a referral to SALT in February but no trace could be found of the referral;
6. There was no evidence of clear clinical review of the outcome of the fluid charts.