Edwina Rose Moses · Prevention of Future Deaths report

On the 23rd September 2016 I commenced an investigation into the death of Edwina Rose Moses aged 78. The investigation was concluded at an end of an inquest dated the 20th December. The conclusion of the inquest was that of a narrative conclusion namely “Edwina Rose Moses, who suffered from complex health issues and dementia died as a result of an upper gastrointestinal bleed having undergone surgery to repair two broken hips after a fall at her home address and a fall in hospital at a time when she was assessed as requiring one to one care”.

The deceased was admitted to hospital on the 15th August having fallen at her home address fracturing her left neck of femur. That was surgically repaired on the 18th August after which, despite some setbacks in terms of respiratory function, she appeared to be making a recovery. She fell from her hospital bed on the 31st August at a time when she should have been receiving one to one nursing care. She fractured her right hip which was surgically repaired the same day. In the following days she became increasingly unwell showing signs of a gastrointestinal bleed and deteriorated and passed away on the 19th September 2016.

1. The evidence revealed that there was a poor system in place for requesting additional nursing cover to provide one to one support. There was confusion by front line staff as to who was responsible for identifying, booking and ensuring that such help was provided.

2. The evidence showed that it was common place for additional nursing cover not to attend and staff were then left to provide one to one cover alongside their main stream duties – which was wholly unrealistic. Given the apparent frequency in which additional nursing cover is “unavailable”, often in the context of dealing with patients suffering with dementia, the issue of appropriate staffing levels on wards and the ability of staff to safely look after patients must be a concern.