Mary Ann LINCOLN · Prevention of Future Deaths report

On 29th May 2020 I commenced an investigation into the death of Mary Ann LINCOLN. The investigation concluded at the end of the inquest on 2nd August 2021. The conclusion of the inquest was a narrative:

“On 18th May 2020 Mary Ann LINCOLN was admitted to Pinderfields General Hospital. It was known that she required walking aides. The falls policy was not implemented correctly. Mrs Lincoln was placed into bed in a single occupancy room at around 2230 on 20th May 2020 and requested the bed rails be placed in the upward position. She had received a significant underdosage of her medication to treat Congestive Cardiac Failure and it is probable that this led to her needed to have an increased need for the toilet and breathlessness. She was last checked at 0240 hours on 21st May 2020. At 0630 she was discovered deceased on the floor of her room with an open fracture of her tibia and fibula. Her bed rails were still in place. It was evident that she had lain there for some time”

COD: 1a Traumatic fracture of right tibia and fibula
2 Atrial fibrillation, pulmonary hypertension, ischaemic heart disease

Narrative covers circumstances. Vulnerable lady, falls policy, medication, bed rails failings.

(1) During evidence it became apparent that there is no guidance or policy with regard to checks on patients overnight (who are not subject to NEWS, turning etc). Mrs Lincoln was put in to bed at around 2130 and only checked once in the night despite being in hospital, having a history of falls and knowledge of the fact she needed the toilet overnight. Although she had previously used the call buzzer she was also known to mobilise herself. She was not discovered until 0630, and then only because someone noticed as they passed her door. She had lain on the floor for some time, with an open fracture. The hospital conducted a serious incident review in which it recommended the checks policy should be reviewed. It appears it was reviewed but no changes were made. Evidence had been heard that previous rounding checks were deemed inappropriate and therefore no further action was required. Therefore there is no policy or guidance with regard to people who are vulnerable, a falls risk and known to get up in the night (for any reason) to be further assessed for checks overnight.

(2) There is a bedrails policy in place, the author of the SI report found that it appeared to be comprehensive. During evidence however the staff responsible for implementing its use were either unaware of it (it appears it is not circulated to HCA’s), or find it confusing. There is obviously a void between producing a policy and ensuring it is circulated and understood by all concerned.