Eileen Annie Thompson · Prevention of Future Deaths report

On 31 December 2015, I commenced an investigation into the death of Eileen Annie Thompson, aged 92 years. The investigation concluded at the end of the inquest on 12 February 2016. The conclusion of the inquest was that Mrs Thompson died from head injuries, namely a fractured base of skull and intracranial bleeding. I recorded a conclusion of accidental death.

Mrs Thompson, who had been diagnosed with dementia, lived with her son and daughter-in-law. She sustained a right-sided fractured neck of femur and was admitted to George Eliot Hospital, Nuneaton, on 1 November 2015. Prior to her discharge from hospital, a site visit was carried out at her address by an Occupational Therapist to assess whether equipment would be needed to assist with Mrs Thompson’s on-going mobility and rehabilitation needs. As a result of this visit, a hoist and a Minuet bed were ordered. Following the delivery and installation of the equipment, Mrs Thompson was discharged from hospital on 20 November 2015.

Due to the size and shape of her room, the bed was positioned along a wall. The bed had four wheels, one on each corner, with a separate locking mechanism for each wheel. The position of the bed against the wall meant that only the two outer wheels could be locked. The two inner wheels (that is, those on the side against the wall) could not be reached once the bed was in position, and so those two wheels were not locked.

During the evening of 29 December 2015, Mrs Thompson’s daughter-in-law discovered that Mrs Thompson had fallen between the bed and the wall. The bed had moved from the wall. Mrs Thompson had sustained serious head injuries. She was taken by ambulance to George Eliot Hospital, where she died shortly after admission.

(1) The bed was able to move from the wall because the two inner wheels were not locked.
(2) The locking mechanism for the inner wheels was not easily accessible when the bed was placed against a wall.
(3) There is risk of recurrence in respect of service users who are provided with this type of bed when the bed is placed against a wall.