Mrs Patricia Irene Walker · Prevention of Future Deaths report

On 11th April 2025, an inquest was opened and adjourned into the death of Patricia Irene Walker aged 87 years. The investigation concluded at the end of the inquest on 27th January 2026, the conclusion of the inquest was accidental death.

Patricia Walker died in Castle Keep Care Home in Bransholme in Hull after being placed on fast-track discharge following an emergency admission to Hull Royal Infirmary.

Her medical cause of death was recorded as:

1a. Acute on chronic bilateral subdural haematoma
1b. Multiple falls
2. Fractured neck of femur (operated), frailty of old age

Patricia Walker lived independently and, although had suffered some confusion and falls in the community, was able to look after herself and visited her husband in Castle Keep care home. She had a supportive family and decided she wanted to live closer to her nieces. She went with her niece to visit a bungalow with view to moving but tripped over shrubbery in the garden of the property and was conveyed by emergency ambulance to Hull Royal Infirmary where she was found to have suffered a fractured neck of femur. She was assessed as a falls risk as she was confused whilst on Ward 12 where she was placed from ED. Ward 12 is a trauma orthopaedics ward. She was admitted on 4th February and fell from the bed which had bed rails up at 03:40hrs. She suffered a head injury and was sent for a CT later that day at 09:47hrs. The scan revealed an acute bilateral subdural haematoma on chronic subdural haematoma which would need to be treated with burrhole surgery. This operation took place on 10th February; her fractured neck of femur having been operated on 9th February successfully but her neurological condition having deteriorated. The operation went ahead as planned but Mrs Walker suffered further falls whilst in hospital when she was transferred to Ward 90 which is one of the five frailty wards in the hospital.
Staffing was sub optimal on Ward 90 at this time, with the staffing model being below the required four RGNs and three unregistered nurses on a day shift and three RGNs and two registered nurses on a night shift. One of the RGNs had been moved to a different ward leaving the ward short staffed on the night shift of 24th February. Mrs Walker suffered a further two falls whilst on Ward 90. Mrs Walker was placed on fast-track discharge and died in Castle Keep care home having ultimately failing to rally with poor nutritional intake and medication refusal and worsening confusion.

(1) Staffing was sub optimal and remain sub optimal on Ward 90 as recruitment is difficult which means that TAG nursing care is not always possible, and patients are at an increased risk of falls.