Douglas ARMSTRONG · Prevention of Future Deaths report

On 17 January 2024 I commenced an investigation into the death of Douglas ARMSTRONG aged 88. The investigation concluded at the end of the inquest on 12 August 2024. The conclusion of the inquest was that:

On 16 December 2023 the Deceased had an unwitnessed fall at his home address. He sustained a fractured neck of femur, but this was not identified either by two responders from an agency or by the district nurse who attended. As a result his arrival at Arrowe Park Hospital, Arrowe Park Road, Wirral hospital was delayed by around 18 hours, and it is likely that his subsequent surgery was similarly delayed, adding slightly to the mortality risk. He died at the hospital on 5 January due to aspiration pneumonia, which resulted from the accidental injury sustained in the fall. It is unlikely that the delay in hospital admission either caused or materially affected the timing of his death.

On 16 December 2023 the Deceased had an unwitnessed fall at his home address. He sustained a fractured neck of femur, but this was not identified either by two responders from an agency or by the district nurse who attended. As a result his arrival at Arrowe Park Hospital, Arrowe Park Road, Wirral hospital was delayed by around 18 hours, and it is likely that his subsequent surgery was similarly delayed, adding slightly to the mortality risk. He died at the hospital on 5 January due to aspiration pneumonia, which resulted from the accidental injury sustained in the fall. It is unlikely that the delay in hospital admission either caused or materially affected the timing of his death.

Following his fall at home the Deceased was visited by two representatives of the care agency. They did not appreciate that he had suffered a fractured neck of femur. They placed more reliance than was justified upon his assertion that he had not hurt himself and was not in pain. The information supplied during their verbal communication with the ambulance service did not result in the latter appreciating the need for a personal attendance or visual assessment.

Fractured neck of femur is a common consequence of falls in the elderly and requires prompt attention. Those providing a response system should have the skills, knowledge and training necessary to identify the problem or to appreciate that they cannot do so, and to communicate the limits of their diagnostic ability to the ambulance service. I was told that the responders acted in accordance with their existing training and have had no additional training since these events, nor was I told that any is planned. I am concerned that responders attending a similar call might be unable to assist effectively and would appreciate their employers addressing this by considering whether opportunities exist to improve the situation.