Mrs Beryl Farmer · Prevention of Future Deaths report

On the 7 September 2016, I commenced an investigation into the death of the late Mrs Beryl Farmer. The investigation concluded at the end of the inquest on 23 November 2016. The conclusion of the inquest was a short narrative conclusion of: Accidental death contributed to by neglect. The cause of death was:

1a Subdural Haemorrhage
II Ischaemic Heart Disease, Hypertension, Left Ventricular Failure, Atrial Fibrillation, Type 2 Diabetes Mellitus, Chronic Kidney Disease

1. Mrs Farmer was a 77 year old woman with a medical history including chronic kidney disease, ischaemic heart disease, hypertension, diabetes, dextracordia and situs inversus. She was admitted to Sandwell Hospital on the 20 June 2016 after experiencing symptoms of loss of appetite, weight loss and nausea.

2. She was diagnosed with severe hypocalcaemia secondary to severe vitamin D deficiency. She also had significant postural hypotension with a drop of 25mmHg on standing. She received intravenous calcium infusions for treatment.

3. On the 23 June shortly after 6am she had a fall from her bed and sustained an injury to her face and head. This resulted in bruising to her right eye area and her forehead. No CT scan was performed at this stage because it was concluded that her GCS was 15/15 and no evidence of vomiting, and her key observations were normal.

4. She was later discharged on the 24 June 2016. No documentation for a falls risk assessment was available or had been completed.

5. In addition a decision had been taken to move her from a monitored area to a de-monitored area prior to the fall without consultation with the medical team.

6. There was also a failure to perform further neurosurgical observations after the first set of observations before discharge.

7. At home, her condition declined and she developed headaches and was readmitted back to Sandwell Hospital on the 1 July 2016. A CT scan was performed on this occasion and a subdural haemorrhage diagnosed.

8. Advice from neurosurgeons was sought and she was managed conservatively. She then effectively remained in Hospital and went on to develop seizures as a result of the subdural haemorrhage and sadly died on the 30 August 2016.

1. Evidence emerged during the inquest that Mrs Farmer had a risk of a falling (moderate to high risk). There was no evidence that a falls risk assessment had been completed.

2. Given the risks of falls, there was no clear justification for moving her from a monitored bay to an unmonitored bay.

3. After the fall, only one set of neurological observations were performed before her discharge.

4. In addition no CT Head scan was performed despite evidence of significant bruising to her face and head.