Robert TAYLOR · Prevention of Future Deaths report

On 4 July 2024 I commenced an investigation into the death of Robert TAYLOR. The investigation concluded at the end of the Inquest. The conclusion of the inquest was; Natural causes contributed to by injuries sustained in a fall when he was not receiving enhanced nursing observations.

Mr Taylor suffered from prostate cancer was frail and had chronic liver disease. On 29/05/24 he fell in the bathroom at his home address after his leg gave way. He was admitted to Birmingham Heartlands Hospital where he was investigated and treated for pancytopenia, possible infection and dropping Hb. He was being nursed in a side room due to the increased risk of infection. In the morning on 11/06/24 he was noted to be very confused and agitated and it was recognised that he required enhanced 1:1 observations. No enhanced observations were put in place. He did have non slip socks and the bed rails were down to reduce the risk of him falling. He received lorazepam to enable a CT scan to be undertaken at 11.06. At around 18.13 he was found face down in his side room with an obvious head injury. A CT scan confirmed bilateral subdural haematomas and a small subarachnoid haemorrhage which were treated conservatively. A bone marrow biopsy confirmed he was sadly suffering from high grade acute myeloid leukaemia and inflammatory markers showed this disease was progressing. He continued to deteriorate and sadly passed away on 21/06/24.

Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be:

1a High grade Acute Myeloid Leukaemia

1b

1c

1d

II Acute subdural and subarachnoid haemorrhage (traumatic)

1. The central issue in this case relating to the fall on 11/06/24 was the lack of enhanced nursing observations. The Nursing witness was unable to say what steps, if any, had been taken to try to put enhanced observations in place. The investigation report stated that enhanced observations had been identified as needed but did not expand on what actions were taken, if any, to obtain enhanced observation nor what actions had been taken after the death to ensure enhanced observations for patients that require them. This raises a concern for future deaths.
2. The witness and the investigation report did not address the central issue relating to the fall and this raises a concern about the quality of post death investigations being undertaken by the Trust. This raises a concern for future deaths.