James McArdle · Prevention of Future Deaths report

On 11th December 2013 I commenced an investigation into the death of James McArdle, born 22/05/24. The investigation concluded at the end of the inquest on 25th April 2014.
The medical cause of death was

1 a Large left sided Subdural Hæmatoma

11 Aortic stenosis

The conclusion of the inquest was one of Accidental death.

The Deceased was an elderly but independent man who suffered from a number of co-morbidities. Having been admitted to hospital on 24th November 2013, he suffered two falls on 5th December 2013, just under 20 hours apart. After the first fall he was assessed by medical staff, and the observations did not indicate a CT scan was needed. After the second fall his condition was not survivable.

Evidence was heard from a senior member of the nursing staff who explained that as a patient at risk of falls, the Deceased was given a call bell to alert staff if he wanted to leave his bed and he could be escorted, but that should he leave his bed staff on the ward would realise he was at risk of falls due to a system that involved patients wearing coloured wrist bands to signify their level of risk. This witness explained that since this incident the use of the wrist band system had been withdrawn and not replaced.

That whatever the thinking was as regards the merits of the coloured wrist band system, the system has been withdrawn and not replaced, and in the process a level of protection against elderly patients at risk of falling suffering a fall has been removed. I am concerned that unless a review is undertaken and some new measure(s) introduced then patients such as the Deceased may be at a heightened risk of falls and future deaths may result.