Carl Edmond EASTMAN · Prevention of Future Deaths report

On 1 August 2024, an investigation was commenced into the death of Carl Edmond EASTMAN, aged 96 years at the time of his death.

The investigation concluded at the end of an inquest heard by me on 17 December 2024 and 5 February 2025 at St Pancras Coroner’s Court.

The conclusion of the inquest was ‘accident’.

The medical cause of death was:
1a traumatic right extra-axial haemorrhage
1b anti-coagulation treatment
1c pulmonary embolus (2018, 2022)

II metastatic prostate cancer

Carl Eastman was admitted to the Royal Free Hospital on 23 July 2024, following a fall at home, which was subsequently found not to have caused any injury. He was admitted to a ward where, on 25 July 2024, he had an unwitnessed fall, which did not result in any significant injury. As a result of this fall, Mr Eastman was transferred to an ‘Enhanced Care Bay’ to reduce the risk of further falls, where he should have been kept under constant observation.

In the early hours of 28 July 2024, Mr Eastman had a second unwitnessed fall at a time when a member of staff should have accompanied him. Following this, staff did not follow practices and procedures in place for patients sustaining falls and there was, at times, a total lack of communication between staff. Mr Eastman was found to have an irreversible bleed on the brain as a result of his fall on 28 July 2024. Mr Eastman died in hospital on the evening of 28 July 2024, as a direct result of the injury sustained in the unwitnessed fall in the ward earlier that day.

1. The consultant geriatrician’s evidence was that CT scan was requested to take place ‘as soon as possible’ following the first unwitnessed fall on 25 July 2024; however, they accepted that this was not conducted in a timely manner.

Further, following the second unwitnessed fall on 28 July 2024, there was a further delay in a CT scan taking place. I was told that this scan should have been conducted within 1-2 hours of the request being made, yet it took place over three hours after the patient was reviewed by the doctor and the request for the scan was made.

In Mr Eastman’s case, the delays in receiving the scans transpired to be immaterial in the particular circumstances. However, I am concerned that if delays in such scans, where traumatic injury is suspected, are repeated in the future, there is a risk that deaths could occur.

2. There was evidence of what I considered to be ‘widespread communication issues’ in the care provided to Mr Eastman. These included:
• When the on-call doctor attended to review Mr Eastman at approximately 02:45 on 28 July 2024, ward staff (incorrectly) told the doctor that nobody had fallen on the ward, which lead to the doctor leaving the ward without Mr Eastman having been reviewed. As the consultant geriatrician said in his evidence, communication between the ward staff and medical staff was not good.
• The evidence revealed that there were deficiencies in basic record keeping.

3. As set out above, there was clear evidence that the Trust has put extensive measures in place to address the issue of staff having not followed the Trust’s own post-fall procedures and protocols. However, I am concerned that the issue may not be limited to just those particular protocols and may be indicative of a wider skills/knowledge deficit.

4. Following on from the matter set out in paragraph 3 above, the evidence revealed a lack of professional curiosity on the part of some staff members (nursing and medical). In my view, this could also be indicative of an underlying skills/knowledge deficit.