William Joseph Wilkinson · Prevention of Future Deaths report

On the 19th of December 2012 an investigation was commenced into the death of William Joseph Wilkinson. The investigation concluded at the end of the Inquest on 9 September 2013. The conclusion of the Inquest was that the deceased died an accidental death.

Mr Wilkinson slipped on the pavement whilst he was out shopping on or about the 9th of December 2012 and he fractured his ankle. He was admitted to the hospital and thereafter complications occurred leading to his death.

A number of issues were raised by members of staff and others about the care at the Royal Bolton Hospital.

(1) I was told that despite one-to-one nursing being required for Mr Wilkinson and indeed being ordered, this is not always available. There was clear evidence that had such nursing standards been available Mr Wilkinson may not have developed the problems which led to his death.

(2) Members of staff reported that they sometimes find it difficult if not impossible to log onto the computer system in the hospital and therefore cannot record matters as they should be recorded. This is apparently due to the inadequacies of the system rather than the inabilities of the individuals.

(3) A Fluid Balance Chart was ordered to be kept and it was accepted that this was not done and an incomplete Fluid Balance Chart resulted.

(4) It was agreed that there was no direct orthopaedic input available at the Emergency Department at the hospital and that it would be sensible for this to have been available. Had this been available Mr Wilkinson would probably not have been admitted to the hospital in the first place with a fractured ankle and therefore would not, presumably, have developed clostridium difficile leading to his death. He was described as an unnecessary in-patient.