Harold Blackshaw · Prevention of Future Deaths report

On 04/03/2021 I commenced an investigation into the death of Harold Blackshaw, aged 72. The investigation concluded at the end of the inquest on 6th August 2021.

The conclusion of the inquest was Harold Blackshaw, who passed away on the 1 March 2021, at Trentham House Nursing Home, Chivelstone Grove, Trentham, Stoke-on-Trent, from COVID-19 had a past medical history of falls and Parkinson’s disease. On the 12 December 2020 he fell at his home address and sustained a right fractured neck of femur. He was admitted to the Royal Stoke University Hospital, Stoke-on-Trent and received a hemiarthroplasty. His hip dislocated once on the 5 January 2021 after he fell at a care home and once on the 17 January 2021 after he fell at the Haywood Hospital, Stoke-on-Trent. There was an opportunity to do a full falls risk assessment on his admission. This was not done. After both dislocations he required further surgery. After the final surgery he was discharged on the 27 January 2021 to Golden Gate Care Home. He contracted COVID 19 whilst resident here. He was further admitted to the Royal Stoke University Hospital on the 19 February 2021 after his health deteriorated. He was discharged to Trentham House Nursing Home for palliative care where he passed away on the 1 March 2021.

The medical cause of death was found to be
1a) Covid 19.
II) Fractured neck of femur, Parkinson's Disease, rheumatoid arthritis, chronic obstructive pulmonary disease.

Harold Blackshaw, who passed away on the 1 March 2021, at Trentham House Nursing Home, Chivelstone Grove, Trentham, Stoke-on-Trent, from COVID-19 had a past medical history of falls and Parkinson’s disease. On the 12 December 2020 he fell at his home address and sustained a right fractured neck of femur. He was admitted to the Royal Stoke University Hospital, Stoke-on-Trent and received a hemiarthroplasty. His hip dislocated once on the 5 January 2021 after he fell at a care home and once on the 17 January 2021 after he fell at the Haywood Hospital, Stoke-on-Trent. There was an opportunity to do a full falls risk assessment on his admission. This was not done. After both dislocations he required further surgery. After the final surgery he was discharged on the 27 January 2021 to Golden Gate Care Home. He contracted COVID 19 whilst resident here. He was further admitted to the Royal Stoke University Hospital on the 19 February 2021 after his health deteriorated. He was discharged to Trentham House Nursing Home for palliative care where he passed away on the 1 March 2021.

During the course of the inquest evidence was given regarding the admission process for patients admitted to the Haywood Hospital. Specifically the rehabilitation ward which Mr Blackshaw was admitted to (“Grange Ward”). It was heard that this ward was primarily for the rehabilitation of elderly patients that were recovering from injuries; some after falls. Some patients were high risk of falls. The evidence given suggested that there was no admission process which assessed the needs of each patient and what measures should be put in place to meet their needs, before they came to the ward, or when they were on the ward. This gives me concern that a future death could result.