Agnes Gwenllian SANSOM · Prevention of Future Deaths report

On Twentieth August 2019 I commenced an investigation into the death of

Agnes Gwenllian SANSOM, aged 95

The investigation concluded at the end of inquest on 6th January, 2020. The conclusion of the inquest was:

I a Hospital Acquired Pneumonia
I b Fractured Neck of Femur (Repaired)
I c Frailty of Old Age

II Left Ventricular Systolic Dysfunction, Stroke

The deceased was admitted to University Hospital of North Durham on 15th July 2019. She was known to be at risk of falling and of suffering serious injury or death in the event of falling.

The deceased was obliged to share a Zimmer frame with another patient on the ward.

On 18th July, a physiotherapist assessed the deceased and observed that she (i) was likely to rise from her bed and mobilise unaided (contrary to nursing advice); and (ii) required supervision when mobilising. These observations were recorded in the deceased’s “Patient Health Record” (a paper document).

Had the physiotherapist’s observations been known to nursing staff or to the Ward Manager, action should have been taken to prevent unaided mobilisation.

Nursing staff relied only upon the Electronic Patient Record System (EPRS) for information about the deceased. The EPRS contained none of the physiotherapist’s observations and no alert as the importance of the same. Neither nursing staff nor Ward manager acted to prevent unaided mobilisation.

Unaided mobilisations continued after the physiotherapist’s assessment and during one such incident, on 20th July, the deceased fell, thereby sustaining the injury which led to her death.

(i) existing patient record systems fail to ensure that important and urgent information is brought, in a timely way, to the attention of those who need it; and

(ii) vulnerable patients are obliged to share walking aids on hospital wards