Harold Graham WONFOR · Prevention of Future Deaths report

On 12/06/2017 I commenced an investigation into the death of Harold Graham WONFOR. The investigation concluded at the end of the inquest 14th September 2017. The conclusion of the inquest was Harold Wonfor was admitted to the William Harvey Hospital on the 22nd of January 2017 with a history of falls which was not recognised. On the 24th of January he had an unwitnessed fall on Cambridge L ward sustaining a Subdural Haematoma from which he declined and subsequently died on the 30th January 2017.
1a Acute Subdural Haematoma
b
c
II Asbestosis

Following his admission to the Kent and Canterbury Hospital on the 21st December 2016, Harold Wonfor sustained a number of falls whilst on the ward. Clinical investigation concluded that there had been no subsequent injury although it was well documented that he was frail, HAD a number of co-morbities and presented a falls risk. He was discharged on the 5th January 2017 into the care of his family.
On the 22nd of January he was admitted in the William Harvey Hospital where he presented as being confused with reduced mobility. He was transferred to the CDU (Clinical Decisions Unit) for assessment.
Hospital policy dictated that a falls assessment should be done within 6 hours of admission but such time should be abridged where the patient is vulnerable or a clear falls risk.
Mr Wonfor was not assessed during the 24 hours he remained in the CDU in contravention of Hospital Policy.
On the 24th of January he was transferred to Cambridge L Ward. At the time of transfer no falls assessment had been done and there were no falls prevention measures in place. At the very least Mr Wonfor should have been met by a Nurse upon arriving on the Ward and placed in an observation bed. This did not happen.
Approximately 30 minutes after arriving on Cambridge L Ward, Mr Wonfor had an un-witnessed fall during which he struck his head on a sink and sustained a Subdural Haematoma from which he subsequently declined and died on the 30th of January 2017.

(1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced. Inquests in respect of each of the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths.
(2) That the policies and procedures for falls risk assessment is inadequate especially for the vulnerable
(3) There is inadequate monitoring and enforcement of the falls prevention policies and procedures in place