Joan Rossington · Prevention of Future Deaths report

On 29 June 2022 I commenced an investigation into the death of Joan Rossington born on 26 September 1937. The investigation concluded at the end of the inquest on 7 November 2022. The conclusion of the inquest was:-

On 16 June 2022 Joan Rossington was an inpatient at the Royal Hallamshire Hospital. She required support with a number of her cares and her own carers were providing her with support during the day throughout her admission. After her carer had left for the day Joan stood from her chair and attempted to move across the ward. She was unable to sustain her balance and fell banging her head. She sustained significant injuries as a result of this fall and died as a result of those injuries at the Royal Hallamshire Hospital on 17 June 2022

She died as a result of an accident.

The medical cause of death was:

1a: Traumatic subarachnoid, intracerebral and subdural haemorrhage
1b: Multifactorial fall
2: Old age and frailty, suspected dementia

Joan Rossington was an inpatient at the Royal Hallamshire Hospital. Whilst an inpatient she was supported by her own care staff. Those staff were present with her during the day and provided routine support to her including assistance with her eating, drinking and personal hygiene.

Joan had a number of care plans and risk assessments which applied to her on the ward including appropriate care plans relating to her risk of falls. Those care plans and risk assessments were not discussed with or shared with her own care staff delivering support to her on the ward.
On 16 June 2022 despite these plans being in place, once her care team had left the ward for the day; Joan suffered a fall in hospital. As a result of this she sustained head injuries which proved to be fatal.

Joan was in receipt of support on the ward from her own care staff. These staff were not included in, or aware of, the risk assessments or care plans which were in place on the ward to support Joan. This had the potential to place Joan at risk of those staff delivering care which was contrary to that which was indicated by medics and clinicians responsible for her. Involvement in care planning and delivery of those supporting Joan would have made this a safer environment for her and the roles and responsibilities of those involved in care should be made clear.