Mr Reginald Frank Lewis · Prevention of Future Deaths report

On the 17 January 2017, I commenced an investigation into the death of the late Mr Reginald Frank Lewis. The investigation concluded at the end of the inquest on 27 April 2017. The conclusion of the inquest was a short narrative conclusion of accident.

The cause of death was:

1a Intracerebral Haemorrhage
b Fall
c
II Bronchopneumonia, Chronic Kidney Disease, Ischaemic Heart Disease, Hypertension

i) Mr Lewis was admitted to New Cross hospital after a fall at home on the 13 January 2017.

ii) He had a medical history including chronic kidney disease, previous myocardial infarction, poor memory, peripheral vascular disease, COPD and worsening confusion. A chest x-ray showed consolidation of the right upper lobe suggestive of pneumonia and he was started on antibiotics.

iii) A CT head scan on admission did not show any intracranial haemorrhage, subdural collection or fractures. He was then transferred from the Acute Medical Unit (AMU) ward to ward C19 which deals with respiratory illness when a bed became available.

iv) He was transferred on the basis that he had mild confusion but it wasn't made clear to staff on ward C19 the extent of his confusion and risk of falls and that he was also registered blind.

v) On the afternoon of the 14 January 2017, Mr Lewis became increasingly agitated and after family had left visiting him he had a fall and sustained a significant head injury. The family maintain they had notified staff they were leaving at the time.

vi) A repeat CT head scan demonstrated a left parietal intraparenchymal bleed. This was discussed with neurosurgeons who deemed he wasn't suitable for surgical intervention. He was also reviewed by the stroke team.

vii) He gradually deteriorated following this with GCS dropping to 3 and sadly passed away on the 17 January 2017 due to the head injury and bleed on the brain.

1. Evidence emerged during the inquest that the patient was left alone unsupervised when family visitors left the ward. It transpired that staff didn’t know relatives had left the ward.

2. On ward c19, there were already six patients on the ward required to be observed 24 hours a day in two bays. Two bays were subsequently closed to diarrhoea and vomiting.

3. Evidence emerged from nursing staff on Ward C19 that they were unable to take any more patients that are confused, wandering or aggressive. This was based on the enhanced scoring tool and the number of patients that required one to one observation.

4. Despite initial reservations, junior nursing staff did eventually accept Mr Lewis into Ward C19 on the basis he had mild confusion and claimed they felt “under some pressure” from senior nursing staff to accept him. This was in contrast to the opinion of the senior Charge Nurse on ward C19 who gave evidence that he still would not have accepted the patient in the circumstances.