Leonard Arthur PRITCHARD · Prevention of Future Deaths report

On 24 February 2021 I commenced an investigation into the death of Leonard Arthur PRITCHARD. The investigation concluded at the end of the inquest. The conclusion of the inquest was Accidental Death.

The deceased died on 18 February 2021 in Good Hope Hospital, Sutton Coldfield, as a result of injuries which he sustained following an unwitnessed fall from a chair in an A&E cubicle on 12 February 2021. He was treated conservatively, but his condition deteriorated over the course of the following days and sadly he did not recover. He was originally admitted as a precaution following an unwitnessed fall at his care home earlier on 12 February 2021, where CT scanning indicated that he did not sustain any acute intracranial injury at that time. He was subsequently assessed in the emergency department as being at a risk of falls by the nursing staff, who implemented appropriate falls prevention measures. He was not provided with a Zimmer frame to allow him to mobilise, and no discussion took place between staff as to how he was to mobilise in the absence of a walking aid.

Based on information from the Deceased's treating clinicians the medical cause of death was determined to be:

1a PNEUMONIA

1b INTRACRANIAL HAEMORRHAGE

1c FALL

II ATRIAL FIBRILLATION (ANTI-COAGULATED), HYPERTENSION, TYPE 2 DIABETES MELLITUS, ISCHAEMIC HEART DISEASE, DEMENTIA

1. During the course of the inquest, I heard evidence that there is an inadequate supply of mobility aids within the emergency department of Good Hope Hospital which are utilised by the Older People Assessment and Liaison (OPAL) team when assessing patient's mobility, and which are given to patients who are identified as requiring an aid. I heard that there are presently 2 zimmer frames, whilst there are 17 cubicles in majors; 5 resuscitation cubicles; 6 trolleys in the new extension of the emergency department; and 8 chairs in the clinical decision unit. I heard from staff that they consider this mobility aid to patient bed ratio was inadequate. There is a clear risk of death for patients who require mobility aids but can not have access to them. The Trust should consider addressing this as a matter of urgency.

2. Linked to 1) above, I heard evidence that procurement discussions are taking place, but from the evidence it is unclear who has overall responsibility for the assessment; selection; and procurement of aids, and neither is it clear when this process will be completed by. The Trust should consider ensuring that this procurement process takes places as a matter of urgency.