Kenneth PERKINS · Prevention of Future Deaths report

On 14 September 2018 I commenced an investigation into the death of Kenneth PERKINS aged 94. The investigation concluded at the end of the inquest on 28 April 2022. The conclusion of the inquest was that:

Kenneth Perkins, date of birth 25th December 1923, of 2 Middlemore Cottages Stanhope Street, Stanton by Dale had a history of recurrent falls. He had a number of co-morbidities – atrial fibrillation, diabetes, trans ischaemic attacks. He attended Royal Derby Hospital on 4th September 2018 following left sided weakness facial droop and confusion. He was agitated, remained confused and lacked capacity. A risk assessment required him to have the assistance of one carer when mobilising; despite this he was wandering in the bed area independently without assistance when he fell and hit his head. The subarachnoid bleeding could not be treated; he was treated palliatively and sadly he died at the Royal Derby Hospital on 11th September 2018.

Mr Perkins was admitted to Ilkeston Community Hospital on 7th June 2018 where full risk assessments were carried out; it was established that he was at high risk of falls. He was transferred to the Royal Derby Hospital on 3rd September 2018. He fell and died at the Royal Derby Hospital on 4th September 2018 and died on the 11th September 2018.

Mr Perkins was transferred from Ilkeston Community Hospital to the Royal Derby Hospital. There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls The Royal Derby Hospital did not (but should have) requested a transfer document. That history would have allowed an enhanced level of care and observation to be put in place so as to prevent further falls.