BERYL MARGARET ELIZABETH GOODE · Prevention of Future Deaths report

On 3rd May 2017 I commenced an Investigation into the death of BERYL MARGARET ELIZABETH GOODE aged 84. The Investigation concluded at the end of the inquest on 22nd August 2017. The conclusion of the inquest was ‘ACCIDENTAL DEATH’. The medical cause of death was:
I (a) Intracerebral Haemorrhage
I (b) Fall
I (c)
II Hypertension & Dementia

On the night of the 30th April 2017 the deceased fell whilst trying to use the commode. She denied any injury; was checked and put on appropriate observations. At around 01.00 hours she was found very confused in the corridor having visited another resident’s room. The staff put this down to a urinary tract infection and did not consider the possibility of a head injury. She was then found on the floor of the corridor at 03.25 hours. As a result of the obvious head injury, the emergency services were called and she was taken to Bedford Hospital where she died on 2nd May 2017.

(1) At no point did the night shift staff consider that a head injury could have been the cause of the deceased’s confusion.
(2) It is accepted that the night shift are not medically trained. However, that makes it all the more important that they are aware of the possibility of a head injury to the residents, even in circumstances where the resident denies an injury.
(3) It is also accepted that the deceased may not actually have had a head injury from the first fall. Nevertheless, without training, the staff were not able to exclude a head injury.
(4) It is also accepted that calling the emergency services some 2 hours earlier would not have prevented her death if she had sustained a head injury in the first fall. However, in certain scenarios, residents in the future may have their lives saved if head injury is considered as a possible diagnosis.