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Investigation and inquest
On 25th January 2020 I commenced an investigation into the death of John Cheetham. The investigation concluded on the 26th June 2020 and the conclusion was one of Narrative: Died from the complications of an unwitnessed fall whilst unobserved during a prolonged wait in the Emergency Department for a hospital bed.
The medical cause of death was 1a) Cerebral oedema; 1b) Intracranial haemorrhage (right parietal haematoma); 1c) Fall; II) Clostridium difficile infection, cervical odontoid fracture, metallic aortic valve replacement, rib fractures
Circumstances of the death
John Cheetham had an accidental fall at his home address and was admitted to Stepping Hill Hospital on 22nd December at 08:11. A CT scan identified he had fractured his odontoid peg and ribs. A decision was made to admit him to hospital. He was a high falls risk, a medical bed was not available due to bed capacity. At 02:00 he remained in the Emergency Department, 18 hours after his arrival awaiting a bed. Whilst unobserved he fell. A CT scan identified he had sustained a subarachnoid haemorrhage from the fall. He was moved to a medical ward at 16:40 on 23rd December from the Emergency Department. A repeat CT scan on 23rd December showed the bleed was increasing. His GCS was 9. His anticoagulation had been reversed and his INR was 1.2. On 31st December his infection markers were raised and on 1st January antibiotics were given for a chest infection. His NEWS improved and on 8th January antibiotics were stopped. On 18th January 2020 he deteriorated with a GCS of 3 and NEWS of 7. A CT scan showed significant cerebral oedema. He had also developed Clostridium Difficile. Treatment was given including anti-seizure medication and antibiotics. He continued to deteriorate and died on 19th January 2020 at Stepping Hill Hospital.
Coroner’s concerns
1. The inquest heard that since the events leading up to Mr Cheetham’s death the Trust has taken steps to reduce the risk of falls in the Emergency Department. The inquest heard evidence that a number of the issues that led to his death are part of a wider national issue.
2. The evidence given to the inquest was that the Trust and all other acute hospitals in Greater Manchester were at that time facing significant challenges in terms of ED capacity. The capacity issues on that day were not one off but had been on going throughout December and continued through the winter months. As a result the ED was regularly overcrowded and elderly, vulnerable patients were regularly waiting for very long periods of time in unsuitable conditions in the ED.
3. The prolonged wait Mr Cheetham had was a result of lack of bed capacity. The inquest was told that this was due to delayed discharges of elderly in-patients back into the community because of challenges faced by adult social care. On the day that Mr Cheetham was waiting for a bed there were over 20 other patients in a similar position waiting for an in-patient bed.
4. The inquest was also told that a shortage of nurses nationally trained to work in ED had meant that the unit was short staffed on the night he fell and suffered a catastrophic injury.
5. In his case a risk assessment was not carried out at the earliest opportunity. The inquest heard that when an ED is facing the demands caused by capacity issues risk assessments are not always prioritised increasing the risks faced by elderly patients at risk of falls.
Information checked against the published report and official responses