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Investigation and inquest
On the 05 July 2023 I opened an investigation touching the death of Maria Francisca Teixeira de Ceita, aged 81 years old. I opened an inquest on the 27 July 2023. The inquest concluded on the 16 February 2024.
The conclusion of the inquest was
“Maria de Ceita died as a result of brain damage caused by an unwitnessed fall while she was a hospital in-patient on 04 July 2023.
The following factors contributed to her death:
(a) Not recording that Mrs de Ceita required one to one supervision on the ward;
(b) Not recording any update to that plan;
(c) Not putting in place on one supervision on 3-4 July 2023; and
(d) Lack of effective communication between staff on the ward.
Circumstances of the death
Maria de Ceita was born on 26 March 1935 in Goa, India. She was 87 years old when she died on 04 July 2023 in North Middlesex Hospital, as a result of an unwitnessed fall earlier that day by her hospital bed, which caused her a fatal brain injury. Mrs de Ceita was known by the Hospital to be at risk of falling and at the time of the fall she should have been under one to one supervision by hospital staff.
Coroner’s concerns
In view of Ms de Ceita's known risk of falling, staff at the Hospital decided to put in place one-to-one supervision. An omission in recording that plan in Ms de Ceita's medical records by the hospital staff led to that plan being effected, which in turn contributed to Ms de Ceita subsequently falling by her hospital bed and sustaining a fatal brain injury.
The matter of concern is therefore the lack of an effective system to document and address the risk of elderly patients falling while in the hospital.
Information checked against the published report and official responses