Irene Muriel FITCHES · Prevention of Future Deaths report

On 26/07/2021 I commenced an investigation into the death of Irene Muriel FITCHES aged 77. The investigation concluded at the end of the inquest on 11/02/2022. The medical cause of death was:
1a) Subdural Haematoma
1b) Fall
1c) Benign Positional Paroxysmal Vertigo
1d)
2 Type 2 Diabetes, Hypertension, Mild Cognitive Impairment
The conclusion of the inquest was: Accident.

Mrs Fitches had a significant past medical history. On 17 July 2021 Mrs Fitches was admitted to Norfolk and Norwich University Hospital due to dizziness, nausea and being generally unwell. Mrs Fitches was diagnosed with Benign Positional Paroxysmal Vertigo and a management plan was put in place. Mrs Fitches was considered medically fit for discharge. On 21 July 2021 Mrs Fitches had an unwitnessed fall in her room and suffered a head injury. Her condition deteriorated and she became unresponsive. Mrs Fitches died on 22 July 2021.

1. The Falls Policy does not comply with NICE Guidelines.
2. Evidence was heard that a Falls Policy was drafted, and a Risk Assessment trialled at the beginning of 2020, the Covid-19 pandemic intervened and delayed its completion.
3. There is no person appointed as Falls Lead. The job application has not yet been advertised, although it is recognised that someone is required to lead the Falls process.
4. Staff will need training and the training package has not yet been developed.
5. Assisted Technology is being considered to alert staff to movements and the needs of patients. This has not been progressed since October 2021 and is still at an early stage.