Barbara Christine Sturgess · Prevention of Future Deaths report

On 15 June 2017 I commenced an investigation into the death of Barbara Christine Sturgess (dob: 15 December 1932; dod: 8 June 2017). The investigation concluded at the end of the inquest on 20 September 2017. The conclusion of the inquest was: -

- Medical cause of death: -
1a Bronchopneumonia
1b Cervical spinal fracture

- Summary of circumstances: -
Died on 8 June 2017 at Ashgate Nursing Home due to bronchopneumonia contributed to by a cervical spinal fracture sustained during a fall at the nursing home on 20 May 2017.

- The conclusion of the inquest was that the death was an accident.

Barbara Christine Sturgess moved to Ashgate Nursing Home from a residential care home due to an increase in her needs. She suffered from a number of conditions including advanced dementia. She needed support and supervision in all aspects of her daily care and due to her confusion she could be resistive to care. Although she was able to mobilise around the nursing home unaided she was assessed as at high risk of falls due to her profile and conditions, including her dementia. She sustained a fall on 20 May 2017 and on attendance at hospital a cervical spinal fracture was diagnosed and she returned to the nursing home. She died on 8 June 2017 of bronchopneumonia which, on the evidence, resulted from the cervical spinal fracture sustained on 20 May 2017.

The Chesterfield Royal Hospital did not inform the nursing home or the GP practice that Barbara Christine Sturgess had sustained a cervical spinal fracture nor of any necessary measures in her care and treatment. Her daughter attended a fracture clinic appointment with her on 24 May 2017 where a Doctor told the daughter that a fracture had been sustained and that care should be exercised in her management on account of the fracture. It was only on 26 May 2017, as a result of enquiries by the nursing home, that formal confirmation of the fracture was provided by the hospital. Although there was no evidence that the failure of the hospital to properly confirm and advise on the fracture was a factor in Barbara Christine Sturgess’s death this did have the potential to adversely affect her wellbeing. Very importantly if there were to be further similar failings in communication it could be that for some patients this could be a contributory factor in death.