Maurice ISAACS · Prevention of Future Deaths report

On the 20th June 2016 I commenced an investigation into the death of Maurice ISAACS. The investigation concluded at the end of the inquest on the 2nd November 2016. The conclusion of the inquest was that of a narrative conclusion:-

“Maurice ISAACS died from the effects of a traumatic head injury which he sustained when he suffered one of eight falls whilst in hospital, against a background of dementia, declining health and frailty”

The deceased suffered from Dementia, Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease and was cared for in his own home by his daughter. When she could no longer manage his care, after a significant deterioration in his condition, he was admitted to hospital acutely on 27th April 2016. On admission he was deemed to be at high risk of falls.

Whilst in hospital he fell on seven separate occasions. He was known to suffer from dementia, and at times was delirium. He was particularly restless and agitated during the night time.

In the early hours of 12th June 2016 he fell from his bed and was found on the floor and was believed to have suffered a head injury. After complaining of a headache and after a fall in his level of consciousness, a CT scan revealed a bleed on the brain. He continued to deteriorate and died two days later.

[BRIEF SUMMARY OF MATTERS OF CONCERN]

(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward.

His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls.

(2) After the final fall, shortcomings were identified in the way that the standard "Neuro Observations" were carried out. They were not carried out in line with Trust Policy. They were conducted by a Health Care Assistant, who had not been trained and who failed to conduct one part of the test for a period of six hours. The omission was not spotted by the qualified nurse whose duty it was to oversee the work of the Healthcare Assistant.