Ian Gilmore HEGARTY · Prevention of Future Deaths report

On 17 June 2024, an investigation was commenced into the death of Ian Gilmore Hegarty, then aged 89 years. The investigation concluded at the end of an inquest heard by me on 23 October 2024 at Poplar Coroner’s Court.

The inquest concluded with a short-form conclusion of ‘accidental death’. The medical cause of death was:

1a hypovolaemic shock
1b traumatic fracture of right femur
1c frailty syndrome, vascular dementia
II HIV encephalitis

Mr Ian Hegarty was admitted to hospital on 5 June 2024, following a fall at home and increased confusion. He did not sustain any traumatic injury as a result of the fall at home.

On 14 June 2024, Mr Hegarty was transferred to the Royal London Hospital for management of his underlying health conditions. He underwent a falls risk assessment following admission, which assessed him as being at moderate risk of falls. The ward put mitigation measures in place to address the falls risk, which included being placed in a bay where all four patients were constantly within the sight of an allocated member of staff who was expected to remain in the bay at all times.

On 16 June 2024, the allocated member of staff left bay. In doing so, they did not follow the protocol that had been put in place to reduce the risk of falls for all patients in that bay. During the period of time in which the allocated member of staff was not within the bay, Mr Hegarty had an unwitnessed fall, causing him to sustain a fracture to his right neck of femur.

Shortly after the fall, Mr Hegarty’s blood pressure dropped. Despite treatment, his clinical condition deteriorated and he died in the Royal London Hospital in the early morning of 17 June 2024.

1) That the plan of care put in place specifically to reduce the risk of falls for multiple patients was not followed.

I heard evidence that an internal investigation into the matter has been commenced but is not yet concluded. As such, there was insufficient reassurance, at the time of the inquest, that the risk is being addressed.