Glenys Lillian Phipps · Prevention of Future Deaths report

On 5/10/2020 an investigation was opened into the death of Glenys Lillian Phipps

The investigation concluded at the end of the inquest on: 8/12/2022

The conclusion of the inquest was recorded as:

Death by Accident.

The medical cause of death was:

1a Subdural haematoma
1b Fall

2. Advanced Vascular Dementia. Hip Fracture, CVA, Osteoarthritis, hypertension,
Pancreatitis, gallstones, poor mobility

Glenys Lillian Phipps was admitted to hospital on 3/9/2020 for investigations of abdominal pain. Glenys suffered with dementia and was confused in hospital. There was an inadequate assessment of her risk of falling and no personalised care plan was developed to reduce the risk. Glenys fell twice in hospital. The second fall on 17/9/20

resulted in a cerebral bleed. Her condition deteriorated thereafter, and Glenys died as a result of the head injury on 21/9/20 at Nevill Hall Hospital.

I heard that a key component of the policy to minimize the risk of falls is a thorough understanding of the multifactorial risk assessment process (MFRA)

Whilst I was informed that all adult nurses were made aware of the risk of falls during their nurse training, they are not trained in the use of the MFRA. It is clear that newly qualified nurses rapidly assume responsibility for the care of a group of patients, often before they can undertake the MFRA training.

The senior nurse who gave evidence and presented the internal investigation into the circumstances surrounding Mrs Phipps’ death, undertaken by Aneurin Bevan University Health Board, confirmed that it would be beneficial to the safety of patients if MFRA processes were taught to student nurses prior to qualification.