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Investigation and inquest
On 31 January 2024 I commenced an investigation and opened an inquest into the death of Margaret Rose MAYCROFT. The investigation concluded at the end of the inquest on 12 September 2024.
The conclusion of the inquest was that Ms. Maycroft “Died from natural causes, to which injuries sustained in a number of recent accidental falls contributed.”
Circumstances of the death
In answer to the questions “when, where and how did Ms. Maycroft come by her death?”, I recorded as follows:
“On 18.12.23 Margaret Maycroft, who had recently suffered a number of falls at home, which had caused an intracranial bleed, and on a hospital ward during a previous admission, was readmitted to Worcestershire Royal Hospital and found to have suffered an ischaemic stroke. During this admission, she suffered two further falls and was found to have sustained a displaced fractured neck of femur. She underwent surgery to repair this fracture, but thereafter continued to decline. She was transferred to the Princess of Wales Community Hospital, Bromsgrove for palliative care, and declined and died there on 27.1.24.”
Coroner’s concerns
1) While at Worcestershire Royal Hospital, Ms. Maycroft sustained a number of falls:
(a) on 5.12.23 in the Emergency Department;
(b) on 19.12.23 in the Emergency Department;
(c) on 23.12.23 in the Acute Frailty Unit.
2) In respect of each of these falls, Matron ████████ gave evidence that whilst staff in the Emergency Department and the Acute Frailty Unit had completed falls risk assessments, no measures to mitigate that risk, such as might be found in a falls prevention, assessment and intervention plan, were documented in Ms. Maycroft’s notes. This meant that no documented falls prevention measures were put in place for her.
3) Furthermore, I heard no evidence at the inquest which satisfied me that the steps have now been taken to ensure falls prevention measures are now being properly considered and documented in both the Emergency Department and the Acute Frailty Unit at the hospital.
Information checked against the published report and official responses