David Bassett COOPER · Prevention of Future Deaths report

On 6th April 2016 I commenced an investigation into the death of David Bassett COOPER aged 81. The investigation concluded at the end of the inquest, with a jury, on 15th December 2016. The conclusion of the inquest jury was that of a narrative conclusion and the medical cause of death was recorded as 1a. Acute on chronic subdural haematoma (traumatic) 1b Recurrent Falls 2. Hospital Acquired Pneumonia.

The narrative conclusion was “following a fall as an inpatient, Mr Cooper died of a traumatic brain injury, to which failure(s) in medical / nursing care contributed”

Mr COOPER suffered a traumatic head injury as a result of a road traffic collision in 1992, from which he recovered, and suffered a stroke in January 2009. He fell in the community and sustained a serious head injury on 12th October 2015 and was admitted to the Princes of Wales Hospital in Bridgend. Whilst in hospital, he was transferred between several wards and up to the time of his death, he suffered 9 separate falls. The final fall on 5th March 2016 caused a subdural haematoma from which he died.

[BRIEF SUMMARY OF MATTERS OF CONCERN]

1. When transfers between wards took place, the evidence revealed that there was a lack of comprehensive hand-over by the transferring ward to the receiving ward especially in terms of identifying the patient’s risk of falls. For example, on ward 18 Mr Cooper was in receipt of ‘1:1’ nursing care, but on transfer to ward 21, not only was that never given, but the evidence suggested it was not considered.

2. The accuracy and completeness of nursing notes and records left much to be desired. For example, on Ward 21 when he fell three times, there was no entry made in the Falls Diary – a document which was supposed to act as a tool for nursing staff to assess whether there was a pattern to the numerous falls being sustained – save for the last fall on 5th March. This deprived staff of the opportunity to see the ‘whole picture’ and to take into consideration the eight falls which he had sustained up to that point.

3. The evidence revealed that there was a distinct lack of “joined up” thinking and a failure to see the “whole picture”. Mr Cooper’s risk of falling was as high when he was admitted in October 2015 as it was when he died in March 2016, but still he sustained 9 falls.

4. As with many other cases involving patients at high risk of falls, the evidence revealed shortcomings in the system used for booking additional staff to provide ‘1:1’ care, revealing a system which left front line nursing staff unable to cope with the challenges in looking after the most vulnerable.