Thomas Luke-Taylor · Prevention of Future Deaths report

On 2nd March 2015 I commenced an investigation into the death of Thomas Luke-Taylor. The investigation concluded at the end of the inquest on 2nd March 2015. The conclusion of the inquest was that "The deceased who had had a stroke fell out of bed and sustained an injury whilst in Bishop Auckland General Hospital. A conclusion of Accidental Death was returned and a cause of death of 1a, Sub-Dural Haematoma. 1b, Head Injury secondary to a Fall and 2, Cerebro-Vascular Disease, Bronchopneumonia and Fractured Left Femur, was found.

The deceased who had had a stroke was in the Stroke Rehabilitation Ward at Bishop Auckland General Hospital where he fell out of bed, suffered a head injury and subsequently died. On admission to the University Hospital of North Durham a staff nurse assessed him as not being at risk of falls. He was admitted following transfer from the Royal Victoria Hospital in Newcastle where he had been assessed at risk of falls following his stroke but the staff nurse was not aware of this. On transfer to Bishop Auckland Hospital a student nurse completed a falls risk assessment and wrongly categorised the deceased as not being at risk of falls. Her involvement in the deceased's care was not properly supervised by a staff nurse. In evidence it was said that the staff nurse who made the initial assessment at UHND made the assessment in good faith based on her professional assessment but that she was relatively inexperienced. Two other staff nurses, who were both more experienced, believed that the fact that the deceased had had a previous stroke would have made him more likely to have been at risk of falls and in the absence of any contraindication would have assessed him as being at risk of falls. The matron who produced the RCS concurred that stroke patients were often at increased risk of falls.

In evidence the Matron was asked whether it might be preferable for the falls risk assessment form to give a presumption that certain classes of patients (for example stroke patients) were at increased risk of falls and should be considered as such unless there were good reasons to the contrary. It was her view that this would not be good practice as each and every patient should be assessed on an individual basis. Whilst that is a laudable outlook it was put to her that if there had been such a presumption then the misclassification by the original staff nurse and by the student nurse might have been avoided and this could lead either in this case or in other cases to a potentially different outcome. The matron's view was that freedom of assessment was nevertheless best practice. I indicated my concern over this issue as to whether there should be a presumption in certain cases of an increased risk of falls and that consideration of this issue would be useful.