John Frederick Wherlock · Prevention of Future Deaths report

On 30th May 2017 an investigation into the death of John Frederick Wherlock, aged 90 years, was commenced. The investigation concluded at the end of the inquest on 23rd February 2018. The conclusion of the inquest was as follows:

The medical cause of death was recorded as
1a) Gastrointestinal bleed
1b) Hip fractures (operated), frailty, chronic kidney disease

The narrative conclusion was recorded as:

Mr Wherlock already had a fractured hip and was at a high risk of further falls. He was left unsupervised and fell again, suffering a second fracture. Sadly his condition deteriorated and he died in Bristol Royal Infirmary on 23 May 2017.

The deceased was an inpatient on Ward 518 at the BRI. He was elderly and confused, had already suffered a fractured hip in one fall, and was at a high risk of further falls. He was left unsupervised and during that time tried to get out of bed: he fell again, fracturing his hip on the other side, and that fracture contributed to his subsequent death.

(1) I was told in evidence that at the time of the accident the ward was being covered by two nurses and two nursing assistants (ie, by 4 staff), but that two of those staff had taken their 1-hour break at the same time; effectively leaving the ward with very little cover. The fall had then occurred when a nursing assistant left the deceased’s bay to help another member of staff to change a bed (leaving him entirely unsupervised).

(2) While I would be concerned in any event that staff had taken their breaks at the same time – given the effect that that would inevitably have on the remaining nurses’ ability to cope with the patients on the ward – I was even more concerned when the nursing assistant who gave live evidence at the inquest told me that this was a practice which was still taking place; despite it having been highlighted and criticised in the serious untoward incident report;