Pauline Hayston · Prevention of Future Deaths report

On the 30th May 2017 I commenced an investigation into the death of Pauline Hayston, aged 81. The investigation concluded at the end of the inquest on the 22nd September 2017.

The medical cause of death was determined to be:-

Ia Bronchopneumonia following Fracture of Neck of Right Femur
Ib Immobility following Artery Atherosclerosis, Hypertension and Diabetes Mellitus
II Coronary Artery Atherosclerosis, Hypertension and Diabetes Mellitus

There was a narrative conclusion that Pauline Hayston died as a consequence of injuries sustained in a residential fall and resulting immobility on a background of naturally occurring disease.

The deceased had a history of pulmonary Hypertension, Atrial Fibrillation, Ischaemic Heart Disease, Congestive Heart Failure and Type II Diabetes. Pauline Hayston, deceased, was admitted as an inpatient at the Royal Bolton Hospital, Minerva Road, Farnworth on the 20th May 2017, with reduced mobility, increased frailty and recent episodes of falls. She was managed conservatively and on the 26th May 2017, sustained a fall whilst in an unwitnessed fall on ward and while attempting to mobilise from her bed. A falls mat in place to alert staff of such un-assisted movement did not activate. By reason of her frailty and co-morbidities, the deceased was assessed as unfit for surgery and her fracture was therefore managed conservatively. Her condition was deteriorating and she died on the 25th May 2017.

The deceased had correctly assessed as presenting a high risk of falls as an inpatient on a ward and nursing staff according to policy where to use of a Rambledguard falls mat. The evidence established that it was correctly positioned.

The Rambledguard falls mat failed to activate upon the un-assisted mobilising of this patient. It was established that:

a. The wireless “WiFi” activated system would frequently cause a significant delay between the patient activating the signal and the signal reaching nursing staff.
b. There had been at least 4 occasions within the experience of the Ward Manager that the Rambledguard mats were not activating at all – in circumstances that the mats were not fit for purpose.
c. The mats had been returned to the manufacturer who were unable to establish why the fall mat had not been activated.
d. The issue of the time delay between activation and nursing alarm was considered by the manufacturer, potentially, to be because of an interference of the signal arising from the number of mats in use in the ward, but there was no evidence that nursing staff received any technical instruction given as to how to resolve this potential operational issue.

1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.

The evidence raises the following concerns:

1. The reliability of the Rambledguard fall mats and its fitness for purpose.
2. The suitability of a wireless “WiFi” activated where several fall mats are in place in proximity to each other.
3. Insertion of instructions to nursing staff where the operational integrity of an essential equipment to alleviate falls risks has been identified.