David Thomas BENDELL · Prevention of Future Deaths report

On 19 July 2024 I commenced an investigation into the death of David Thomas BENDELL aged 79.

The investigation concluded at the end of the inquest on 03 June 2025.

The conclusion of the inquest was:

Narrative Conclusion - Accidental death, contributed to by underlying ill health.

The medical cause of death was confirmed as:

1a Large Right Traumatic Subdural Haematoma
1b
1c
1d
2 Chronic Myelomonocytic Leukaemia, Thrombocytopenia, Stroke, Frailty

David Bendell’s death was recognised at 02:49 on 13th July 2024, at The West Suffolk Hospital, Bury St Edmunds in Suffolk.

On the evening of the 12th July 2024 David had been found by his carers (who attended four times daily), injured and slumped on the sofa, so the emergency services were summoned.

David told his carers he had fallen whilst trying to use the commode and shortly after saying this, David became unresponsive and began having seizures.

A CT scan undertaken on David after his arrival at the West Suffolk Hospital identified that he had a large bleed to his brain, which was not survivable.

David suffered from a blood cancer (leukaemia) which made his blood less able to clot (thrombocytopenia), which would have increased the severity of the bleed to his brain.

David had been discharged from hospital on the 8th July 2024 following a recent stroke, and although deemed able to transfer (move from his bed to a commode and return) he was unable to walk.

At the time David fell in his home accommodation (warden-controlled housing) no rehabilitation support staff, or carers were present or immediately available to assist him.

1. At inquest it was heard in evidence David was discharged from hospital once he was able to transfer from a hospital bed to a commode, and back to the bed. It was acknowledged that David could not walk unaided.

2. David was discharged on the 8th July 2024 under the Stroke Early Supported Discharge Team, that was to provide physiotherapy support in his home on a daily basis. David also had carers to attend four times a day (this being the maximum support available).

3. David’s family described how the ambulance team that brought David home considered taking him straight back to hospital as they did not think he would be able to manage at his home. In addition, one of the first physiotherapists to see David reportedly said ‘this is not going to work’ to family members on seeing David in his accommodation.

4. In evidence it was heard that David’s condition was such that he was not a candidate for hospital-based rehabilitation on a specialist stroke rehabilitation ward. This meant that the only available treatment option for David was to treat him at home.

5. The court was told that there is no step-down community rehabilitation facility to act as a ‘half way house’ for patients like David, if like David they are not eligible for inpatient rehabilitation, but are in reality not physically capable of keeping themselves safe when alone at home.

6. I am therefore concerned that with the current rehabilitation options available being either in a specialist hospital ward or at home, other individuals in David’s situation who are not deemed suitable for in-patient hospital, will also be placed at risk by being sent home when it is not safe to do so.