Stanford Shirley Bell · Prevention of Future Deaths report

On 16/3/18 I opened an inquest into the death of Stanford Shirley Bell who, at the date of his death was aged 82 years old. The inquest was resumed and concluded on 30/7/18
I found that the cause of death to be: -
1a Status epilepticus
1b Acute on chronic subdural haematoma
1c Traumatic head injury
II Alzheimer’s dementia and type 2 diabetes mellitus

I arrived at a conclusion of Accident

Mr Stanford Shirley Bell who was diagnosed with dementia, had fall at Riverview Nursing Home, Stourton Road Ilkley on 22/2/18. Upon his admission to Airedale Hospital he was found to have sustained a laceration to his upper lip and several broken teeth. After treatment and a neurological assessment he was discharged back to his care home.

Subsequently after suffering several seizures throughout the early morning, his GP attended and after examination immediately referred him back to Airedale Hospital where a CT head scan revealed that he had suffered an acute on chronic subdural haematoma to which he succumbed and died on 2/3/18. It was found more likely than not that he sustained the acute subdural haematoma as a result of his fall at the care home on 22/2/18.

During the evidence I heard that Mr Bell was discharged from the hospital without discharge papers and that no written reference was made to recommendations about neurological observations. I also heard that during the early morning of 23/2/18 Mr Bell suffered several seizures at the care home and that there was a lost opportunity for the care home to refer him earlier to hospital for the treatment of his seizures, although earlier referral would not have affected the outcome.

• For Airedale Hospital to review procedures at hospital discharge with respect to patients neurologically assessed with head injuries given the absence of discharge papers
• For Riverview Care home to review procedures at the care home with respect to referral to hospital of patients suffering from seizures after a recently sustained head trauma.