Mr Royston Kemp · Prevention of Future Deaths report

On 30th March 2016, I opened an investigation and on 26th March 2019 an inquest into the death of Mr Royston Kemp (00822-2016 MM), 85 years, who died at Queen Elizabeth Hospital on 20th March 2016.

The medical cause of death of Mr Kemp’s death was recorded as follows:
a Pneumonia
b Aspiration
c Advanced Dementia
II Fragility fracture of left hip - operated. Infected venous ulcers.

Whilst the main cause of death was natural and he was at high risk from his fragility, the immobility from a traumatic fracture was a key contributor to his death. The circumstances that led to the fracture in the care home cannot be determined.

Mr Kemp was an uncomplaining 85 year old suffering from dementia and with a history of fractures and falls who suffered an unwitnessed traumatic fracture of his left femur on or soon before 26th February 2016 in his care home. He injured his hand and elbow on 25th, had a bruise on his thigh on 26th, had a need for increased analgesia and a swollen leg on 27th. He was examined by a nurse on 27th but not referred to hospital until 28th when a massive bruising was discovered. He was in a poor state. Despite surgery on 29th and rehabilitation he died peacefully at 21.34 on 20th March from a chest infection and dementia.

A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was:
1) She found one leg more swollen than the other and of a different temperature
but took no action
2) She failed to establish the care assistant’s concern or whether she had met the
concern before or after her assessment
3) She failed to measure Vital Signs
4) She failed to escalate to medical care or refer, in the process failed to enable a
diagnosis of fractured femur to be made.