GEOFFREY WILLIAM HILL · Prevention of Future Deaths report

On 18/2/21 I commenced an investigation into the death of GEOFFREY WILLIAM HILL aged 82. The investigation concluded at the end of the inquest on 13/5/21.

The medical cause of Mr Hill’s death was recorded as;

1a) Traumatic Subdural Haemorrhage

The conclusion of the inquest was Accidental death.

On the morning of 4/2/21 Mr Hill, an 82-year-old gentleman was admitted to hospital with Covid-19, reduced mobility and feeling generally unwell. He arrived in the A & E department at approximately 10.13 am and was seen immediately by a medical doctor. Whilst in the emergency department and awaiting test results, at approximately 17.25. Mr Hill was witnessed to fall from the end of the trolley bed, landing on the floor hitting his head. Mr Hill was conscious but had sustained an obvious head injury. He was seen again by a Doctor and scoop stretched back onto the bed trolley to await a CT scan of his head whilst neurological observations were undertaken. His observations remained unchanged until at approximately 9 pm when Mr Hill deteriorated and became unresponsive. A CT scan identified a very large acute subdural haematoma with significant midline shift. Mr Hill’s head injury was managed conservatively, and he sadly passed away in hospital in the early hours of 5/2/21.

There was a delay in arranging the CT scan after the fall due to Mr Hill’s Covid status, but this did not affect the outcome.

(1) Mr Hill remained in the A & E isolation area for over 7 hours without any falls risk assessment being conducted. He was placed on a bed trolley with the bed rails down and a call bell within reach. He was barefoot at the time of the fall. Mr Hill was not subject to any advanced observations prior to his fall. Mr Hill was noted on admission to be suffering with reduced mobility, having been ‘off his legs’ and was noted to be ‘mildly confused’ at times;

(2) The inquest heard in evidence that there were no national guidelines on the use of falls risk assessments in A & E departments;

(3) The inquest heard in evidence there was no national requirements or guidance for a trolley rail assessment to be completed in A & E;

(4) As Mr Hill did not present with a fall or recurrent falls there was no requirement for any generic or multi factorial risk assessment to be conducted;

(5) An investigation revealed no abbreviated mental test (AMT) had been conducted on admission to ED;

(6) An investigation revealed no therapy assessment had been conducted as Mr Hill remained in the isolation area awaiting the results of further tests;

(7) An investigation revealed no falls prevention information was provided to patients attending the emergency department;

(7) I am concerned that vulnerable and elderly patients in A & E can spend long periods without any falls risk assessments being undertaken placing them at risk.

(8) It was noted that the specific hospital concerned has decided to introduce a shortened version of the falls risk assessment in A & E along with a trolley rail assessment and has displayed a number of posters alerting staff to falls risk in A & E. These actions were welcomed by the Coroner however the Coroner invites NICE to consider introducing national guidelines for ALL A & E departments across England & Wales.