Robert Henry Payne · Prevention of Future Deaths report

On the 23rd July 2014 I commenced an investigation into the death of Robert Henry Payne, investigation concluded at the end of an inquest on today's date which is the 14th April 2015. The conclusion of the inquest was a narrative conclusion

“Robert Henry PAYNE died as a result of infection which he suffered having undergone surgery to repair a fractured neck of femur which he sustained in a fall at his home address on 9th May 2014 and which required further surgery as a result of a further fall and dislocation which he sustained whilst in hospital”.

The deceased was admitted to the Princess of Wales Hospital in Bridgend on the 9th May 2014 having fallen at his home address and fractured his left neck of femur. The femur was repaired on the 9th May 2014 and he was managed on the ward. He fell on the ward, not sustaining any injury on the 12th May and again on the 17th May. He was transferred between two wards in the small hours of 20th May and within hours fell again dislocating the hip which had been repaired. This necessitated further surgery and it became apparent that the surgical wound had become infected. He had one further fall on the 2nd June whilst in the care of physiotherapists. His condition deteriorated and he passed away on the 13th July.

(1) Despite repeated falls risk assessments identifying the deceased as being at high risk of falling he fell on no less than four occasions whilst in hospital which necessitated further surgery as a direct consequence of the fall on the 20th May 2014.
(2) He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.