John Graham SMITH · Prevention of Future Deaths report

Mr Smith had been admitted to Wythenshawe Hospital Manchester on 13th September 2015 following a fall in his garden. He looked after his wife who had dementia and he himself had been diagnosed with dementia. Despite concerns from paramedics (who made a safeguarding referral), his family and ████████ (CPN), who advised an intermediate care assessment, he was discharged home.

It was clear to all that Mr Smith had incontinence problems and had to walk upstairs to the bathroom. He was unsteady on his feet and the stairs at home were difficult to navigate. He also struggled to look after himself. He was discharged home on 22nd September 2015.

Mr Smith was re-admitted to Wythenshawe Hospital on 24th September 2015 following a fall at his home address. He underwent surgery to repair a fractured neck of femur on 26th September 2015 and post surgery he developed aspiration pneumonia and died at 23.59 hours on 1st October 2015.

1. Inadequate risk assessment prior to discharge – evidence heard in court confirmed that the assessment was done using 3 standard steps/stairs. There was no consideration of toilet needs requiring urgent toileting and Mr Smith having to climb a difficult staircase in a hurry. Further, there were professional and family concerns raised regarding discharge.

2. Inadequate questioning for assessment and discharge purpose ████████
Consultant Orthopaedic Surgeon, agreed in court that he would not have discharged Mr Smith knowing the above.

As a result of the discharge of a mobility and incontinent comprised patient, also suffering with dementia and caring for his wife who also had dementia (in respite care prior to Mr Smith’s discharge) Mr Smith suffered a further fall at home which lead to his death indirectly.