John William Wright · Prevention of Future Deaths report

On 23 April 2013 I commenced an investigation into the death of John William Wright. The investigation concluded at the end of the inquest on 4 October 2013. The findings at the inquest were that the medical cause of death was bronchopneumonia, caused by or as a result of Chronic Obstructive Pulmonary Disease (COPD) and a fractured spine and left humerus and the conclusion as to his death was that he died as the result of an accident.

Mr Wright had a history of paranoid schizophrenia and COPD but in February 2013 his mental health appeared stable. He lived in sheltered accommodation and was admitted to the North Middlesex Hospital on 28 February with pneumonia. Despite precautions such as side bars on his bed, he had a fall from his bed that same day with no apparent adverse effects and a further fall at around 8am on 1 March 2013. At around 9:30am on 1 March 2013 he fell in the corridor but the exact cause of the fall was not clear as it was only barely observed by the doctor who was passing. There was no obvious cause and the only observation was that his pyjama trousers were ‘round his knees’. It was noted that he had a left shoulder deformity, an open fracture of the humerus but no obvious head injury. He was stabilised and taken to the Intensive Care Unit and then transferred to the Royal London Hospital where he was treated conservatively. He suffered recurrent chest infections from which he died on 15 April 2013 at 18:45.

1. There was no investigation of the cause or potential cause of the fall (whether there were any external factors involved – water on the floor, over-cleaning or any other high risk matter) so as to ensure that further falls could be prevented if necessary. Even if it transpired that the cause could not be determined, the fall should have been treated as a Serious Untoward Incident that warranted some kind of investigation. The North Middlesex University Hospital NHS Trust Serious Incident Policy defines as ‘serious’ an ‘Accident while in hospital’ and I consider that such a fall should be considered to be an accident. The policy then details actions that should be taken by staff dependent on the urgency of the incident and the evidence that I was given confirmed that the appropriate electronic records were not made following the incident.

2. It was not at all clear from the evidence whether the training on falls policy and the protocols related to the recording of witnessed falls extended to the doctors as well as nurses and it is clear that, as a fall may be witnessed by any staff member at a hospital, the proper protocols should at least be known even if access to electronic means of recording an incident is limited for reasons of confidentiality.