Elaine Marilyn GILES · Prevention of Future Deaths report

On 29th May 2014 I commenced an investigation into the death of Elaine Marilyn GILES, age 66. The investigation concluded at the end of the inquest on 4th December 2014. The conclusion of the inquest was ACCIDENT.

Elaine was a generally fit 66 year old woman who fractured her left neck of femur in a minimal trauma fall at work. She had an uneventful operation with the insertion of a prosthetic hip. She required 10 days of post-operative care in hospital before discharge. Her care was complicated by recurrent nausea, difficulty in pain control, dizziness, feeling faint, and swollen feet. This all interfered with her rehabilitation. Evidence was presented at the inquest that she had been pronounced "safe" in walking with an aid and "safe" on stairs. Once at home it became clear that Elaine was not "safe" on her stairs at home. The problems she had included foot swelling to the extent that her slippers did not fit securely. 5 days after her return home she fell whilst descending the stairs. There were no obvious signs of injury but she took more than a minute or two to recover. She had a telephone conversation at 5pm that evening, but was found dead at 1pm the following day. Whilst it is difficult to estimate the time of death with any precision it is likely that she died about 12 hours or so before she was found. The cause of death at post mortem was fat embolism. The likely cause of the fat embolism was jarring of her hip joint prosthesis in the fall. Forcing fatty material from her bone marrow into the systemic circulation.

1. Whilst assessed as "safe" on stairs prior to discharge from Peterborough City Hospital, it is very clear that Elaine could not negotiate stairs safely when she got home. This tragic case draws attention to the need for detailed assessments of a patient's likely functional performance in their home circumstances after discharge and the importance of ensuring adequate support is available in the home environment.