Mr John Patrick Fox · Prevention of Future Deaths report

On 7th January 2014 I commenced an investigation into the death of Mr John Patrick Fox, aged 93 years. The investigation concluded at the end of the inquest on 4th march 2014.

The conclusions of the inquest were as follows:

Injury or disease causing death:
I (a) Ventricular arrhythmia
(b) Ischaemic heart disease, atrial fibrillation, heart failure and aortic regurgitation
(c) pneumonia

II Fractured neck of femur (surgery 23/12/2013) and osteopenia.

How, when and where Mr Fox came by his death:

Mr Fox sustained an accidental fall at his home address on 22/12/2013. He fractured his left neck of femur and was admitted to St Georges Hospital. Despite all active treatment for his fracture and underlying heart problems, he died on 01/01/2014.

Conclusion of the coroner as to the death:
Accidental fall in combination with severe underlying natural disease.

Evidence was taken from his daughter that Mr Fox had a severe kyphosis and ankylosing spondylitis. This would have meant that he was at high risk of chest infection post operatively, making early mobilisation and physiotherapy especially important. During his in patient stay there were 3 bank holidays and a weekend, during which the access to physiotherapy was limited to an on call service only.

That there is a reduced level of physiotherapy services on bank holidays and weekends, increasing the risk of post operative complications developing in vulnerable patients.