Martin Dilwyn McCabe · Prevention of Future Deaths report

On the 18th September 2014 I commenced an investigation into the death of Martin Dilwyn McCabe aged 66. The investigation concluded at the end of an inquest on the 19th November 2014. The conclusion of the inquest was Narrative Conclusion “Martin Dilwyn McCabe died as a result of the effects of a head injury which he sustained when he suffered an unwitnessed fall on ward 15 of the Royal Glamorgan Hospital on the 14th September 2014”, medical cause of death was 1a. Extensive Bilateral Subdural Haemorrhage 2. Myelofibrosis

Mr McCabe was admitted from an inpatient clinic on the 11th September 2014 onto ward 15 of the Royal Glamorgan Hospital. This was because he was experiencing bleeding from his gastrointestinal tract. This was successfully treated. He was being assisted by a nurse on the evening of the 14th September out of bed to use a “bed bottle” and was left unattended after which he fell to the ground and suffered a serious injury to his head. A CT scan revealed extensive bilateral subdural haemorrhage as a result of the fall. He passed away the following day on the 15th September 2014.

[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) Upon his admission to ward 15 on the 11th September no risk assessment in relation to his risk of falling was carried out. Staff relied on a risk assessment which had previously been carried out 3 months before this admission and did not update it with relevant information such as a history of two falls whilst at home and also the use of night time sedation whilst on the ward. Both of these factors were accepted by the health board to be material factors in a risk assessment and which may well have had a bearing in the way in which staff dealt with him on the ward.