Mr Ronald Compson · Prevention of Future Deaths report

On the 29 November 2017, I commenced an investigation into the death of Mr Ronald Compson. The investigation concluded at the end of the inquest on 18 January 2018. The conclusion of the inquest was a short narrative conclusion of accident.

The cause of death was:

1a Subdural Haematoma
b Fall
c
II Parkinsons Disease

i) Mr Compson had a medical history including Parkinsons disease and was admitted to Russells Hall Hospital on the 16 November 2017 after a period of confusion and drowsiness.

ii) He was initially treated for sepsis and then later his medication for Parkinson’s revised.

iii) On the 18 November 2017 at 9.40pm he had an unwitnessed fall from a chair near his bed and sustained a head injury. Initially his neurological observations were within normal range.

iv) There was a failure to notify a Doctor and no examination took place by a Doctor until the following morning at around 3.30am. At this stage he had vomited on two occasions and a CT scan was requested.

v) His condition declined and he became unresponsive at around 7am and a CT scan revealed a subdural haematoma.

vi) He wasn’t deemed suitable for neurosurgery and placed on an end of life care pathway and sadly died on the 25 November 2017.

1. Evidence emerged during the inquest that there was a failure to contact a Doctor and it isn’t clear if this was a system failure through the “nerve centre” system designed to inform the on call Doctor.

2. There were two separate incidents of vomiting and poor record keeping of when these occurred.

3. There was poor communication to the family about the initial fall.