William Arthur John SIMONS · Prevention of Future Deaths report

On the 16th October 2020 I commenced an investigation into the death of the late William Arthur John SIMONS, 93 years of age. The investigation concluded at the end of the inquest on the 20th and 27th day of April 2021.
The conclusion of the inquest was that the deceased died following two falls the second of which was the more significant and preventable.

Mr Simons was admitted to the Royal Shrewsbury Hospital by his GP on the 21st August 2020 where he stayed undergoing treatment. Before that treatment was completed there were two intervening events which caused or contributed to his death. The first was a fall on the 23rd August 2020 on Ward 22 F when he fell having been to the toilet. The nurse who escorted him waited outside but was called away to another patient. Mr Simons having finished left the toilet without using the call bell. He was found lying on the floor. It was later discovered he had fractured his hip and underwent surgery. On the 8th September 2020 then on Ward 22 T&O Mr Simons had a further fall when he was returned to his bed having been taken by wheelchair for a Doppler scan on his left leg. On returning Mr Simons to the ward no one was available and the porter assisted Mr Simons without a nurse. Mr Simons walked about 2 meters with his zimmer frame but lost his balance and fell back hitting the back of his head on the floor. Both falls contributed to his death with the second the more significant of the two.

(1) The Tele-tracking system

a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it.
b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly.
c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame.

(2) Assistance.

It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available.

(3) Risk awareness.

The porter did not know the patient’s level of risk of falls.