Margaret Ann Richardson · Prevention of Future Deaths report

On [26 January 2016] I commenced an investigation into the death of Margaret Ann Richardson. The investigation concluded at the end of the inquest on 17 August 2016.

The conclusion of the inquest was a Narrative conclusion : . On 5 September 2015, the deceased was admitted to Kitwood ward St Margaret’s Hospital Epping. She suffered a number of falls and she died on 25 January 2016 in Princess Alexandra Hospital Harlow. At least the last fall may have contributed to her death. There were failings in the implementation of the North Essex Mental Health Partnership Trust’s Prevention and Management of Falls Policy in Kitwood ward.

The cause of death was 1a) Bilateral pneumonia 1b) subdural haematoma, ischaemic heart disease

The deceased suffered at least 5 falls while a patient in Kitwood Ward at St Margaret’s Hospital Epping and she died in Princess Alexandra Hospital Harlow after the last fall.

(1) a robust, comprehensive Action Plan with timescales’ needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.