Neil Francis Edwards · Prevention of Future Deaths report

On 12/05/2023, an investigation was opened touching upon the death of:

Neil Francis Edwards

The investigation concluded at the end of the inquest on 08/03/2024.

The conclusion of the inquest was recorded as a narrative conclusion in the following terms:

Neil Francis Edwards was admitted to the Grange University Hospital in Llanfrechfa on 12/04/2023 in respiratory failure. He was at a high risk of falling and required 1:1 observation throughout the entirety of his admission.

Mr Edwards was transferred to Ysbyty Aneurin Bevan where he suffered a fall on 01/05/2023 and fractured his hip. He was not being observed at the time. Mr Edwards underwent surgery to repair his hip on 03/05/23 at the Grange University Hospital.

Postoperatively Mr Edwards suffered a gastrointestinal bleed contributed to by the stress of the fracture and the necessary surgery. He did not have the physiological reserve to withstand the effects of the haemorrhage and he died at Nevill Hall Hospital 09/05/2023.

His death was contributed to by neglect.

The medical cause of death was:

1a) Upper gastrointestinal bleed

2) Fractured neck of Femur (Operated). Chronic Obstructive Pulmonary disease

It was determined that Neil Francis Edwards should have been under 1:1 observation from the time of his admission until at least the time he fell and sustained the hip fracture on 01/05/23. Mr Francis suffered 4 falls whilst in hospital and was not being observed on any of these occasions. The trauma associated with his final fall and the requirement for surgery resulted in a stress-related gastrointestinal haemorrhage and his death.

The inquest was advised that a Falls Panel had been convened to determine, in part, whether action could have been taken to prevent a fall which had occurred on 23/04/23.

I received no evidence that there had been any investigation into the other falls including, importantly, the fall on 01/05/23 that contributed to Mr Edwards’ death.

The court regularly hears that investigations into the circumstances of in-patient falls is central to minimising the risk going forward. It is of concern that no such investigation was undertaken at this time.

Additionally, as there was no investigation, the court was not reassured as to how deaths in similar circumstances might be prevented in the future.