Mrs Maureen Brown · Prevention of Future Deaths report

On the 12th November 2019, I commenced an investigation into the death of Mrs Maureen Ann Brown. The investigation concluded at the end of the inquest on the 3 February 2020. The conclusion of the inquest was a short narrative conclusion stating:

“On the 1 June 2019 at the Coach House, Derby Road, Milford, Belper, Derbyshire, from a subdural haemorrhage caused by a fall whilst a patient at the Royal Derby Hospital. On being transferred from MAU to ward 405 information relevant to her falls risk assessment was known, but not recorded within the electronic transfer information. As a consequence ward 405 were not made aware of information which would have led the deceased having an increased supervision care bundle”.

The cause of death was:

1a Subdural haemorrhage due to;
1b Fall.

i) Mrs Brown was admitted to the Royal derby Hospital on the 16th April 2019. This was following a referral from her GP. This was for a urine sample showing pseudomonas, and the need for intravenous antibiotics. She was admitted under the Medical Assessment Unit (“MAU”) and transferred to ward 405.

ii) Before her transfer, Mrs Browns’ daughter made the staff on MAU aware that Mrs Brown was increasingly confused due to the infection and may try and get out of her bed and as such was at an increased risk of falls. In addition, she disclosed that Mrs Brown had had a previous fall whilst she was a patient at the Royal Derby Hospital.

iii) When a patient is ready for transfer an electronic handover is completed by the transferring ward. This is the only information that the receiving ward have access to at the point of accepting a patient to their ward. The information given by the Mrs Browns’ daughter, was not recorded in the electronic handover.

iv) On being admitted to Ward 405 a Falls Risk Assessment was carried out, based on the information received from MAU. She was deemed to be a high risk of falls and falls preventions measures were put in place. These included bed rails and a call buzzer. She was placed onto a normal ward. However, had the information supplied by Mrs Browns’ daughter been included on the electronic transfer information, Mrs Brown would have been assessed as a high Risk of falls as well as needing an Increased Supervision Care Bundle.

v) An Increased Supervision Care Bundle would have meant that Mrs Brown would have been put onto a ward with only 3 other patients, rather than a full hospital ward, and there would have been constant supervision by a nurse.

vi) She subsequently fell from her bed. This caused her to suffer a bleed to the brain from which, she did not recover.

vii) It was accepted by the Royal Derby Hospital that had Mrs Brown been on the Increased Supervision Care Bundle, it was more likely than it was not that she would not have fallen.

1. Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred. Other relevant information, that is necessary for an effective handover to take place, can be missed as the electronic transfer system limits how much information can be recorded.

2. Evidence was heard regarding the steps that the Royal Derby Hospital has made to remedy this issue. However, the national policy still states that the only piece of information necessary for a transfer is the electronic transfer information.