ANN MARY WELLS · Prevention of Future Deaths report

On 28 December 2013 I commenced an investigation into the death of ANN MARY WELLS, AGED 77 YEARS. The investigation concluded at the end of the inquest on 2 September 2014, the conclusion of the inquest being a narrative conclusion: “Traumatic intracerebral haemorrhage (a) fall with head injury”, and short form conclusion: Accidental Death.

Ms Wells was a resident on Sarndingham Ward, Julian Hospital, Norwich (providing care and treatment for those with complexities in later life) and was mobile with the aid of a 3 wheeled Zimmer frame. She had a fall in her room at a time when she was sleeping. On 21 November 2013 Ms Wells was found on the floor of her room. She told staff she had accessed her room from the wall beside her bed. She had a call bell on the wall beside her bed. She was taken to a local hospital where she was diagnosed with a fractured pelvis and a further fall. Her condition deteriorated and Ms Wells died on 28 December 2013.

(1) A light switch was positioned on the wall beside Mrs Wells’ bed (see attached a photograph). Mrs Wells was 77 years of age, frail with scoliosis, osteoarthritis and a history of falls. In light of the fact that she had been diagnosed with dementia and had a sitting position in bed, it could have been reasonably foreseen that she might attempt to reach for the light switch. Her fall resulted in a fractured pelvis and subsequent complications.

(2) No risk assessment had been carried out with regard to Mrs Wells being placed in this particular room.