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Investigation and inquest
On the 1st May 2018, I commenced an investigation into the death of Rodney Gates aged 84. The investigation concluded at the end of the inquest on 2nd March 2021. The conclusion of the inquest was
Misadventure contributed to by neglect
Circumstances of the death
On the 5th April 2018, Mr Gates crossed the A2 High Street, Newington Kent, passing in front of a HGV which was waiting at temporary traffic lights set up to manage traffic flow whilst the carriage way was excavated to repair a leaking water pipe.
As he crossed directly in front of the vehicle, it was beckoned forward by the traffic management operative, clipping Mr Gates’ shoulder and causing him to fall to the kerb and sustain injury.
He was admitted to Medway Maritime Hospital by ambulance and was diagnosed with fracture of the right proximal femur, which was known to carry a high risk of bleeding, such risk being increased by reason of Mr Gates’ age and coronary artery disease.
He was appropriately managed and admitted to the ward at approximately 1 am on the 6th April 2018, with a plan to operate later that day.
Throughout, Mr Gates’s blood pressure had been low and although his NEWS score had been zero at the point of entry to the hospital it had risen to 3 at the time he was transferred to the ward.
It subsequently dropped to a score of 2 which pursuant to the NEWS protocol required 2 hourly observations at a minimum. In any event the observation rate had been set at every 2 hours by treating clinicians due to the need to monitor for any deterioration due to bleeding at the fracture.
Those observations were undertaken until 6.30 am on the 6th April 2018 after which they were not performed again until 1.15 pm (nearly 7 hours later) when it was recorded that Mr Gates’ blood pressure had dropped such that it was apparent that there was a significant and serious bleed from the fracture site and which required immediate medical intervention. His deterioration during this 7 hour period had not been identified.
Despite appropriate management including transfusions Mr Gates continued to decline and arrested at approximately 3.45 pm and died despite resuscitation attempts.
The medical cause of death was
1a Hypovolaemic shock following recent osteoporotic comminuted fracture of the proximal right femur ( awaiting definitive treatment ) in a patient with coronary artery disease and myocardial infarction
II Hypercholesterolaemia, road traffic collision
Coroner’s concerns
(1) the failure to undertake at all the required observations of a patient pursuant to clinical direction and / or the NEWS protocol which was directly attributable to the conditions of the nursing staff on the ward, those being -
(2) the overall low number of nursing staff both within the A&E department and on the ward
(3) the reliance on agency nurses
(4) the lack of experience and narrow spectrum of skill set of the nursing staff
(5) the lack of equipment available to nursing staff on the ward
Information checked against the published report and official responses