THOMAS PATRICK MAHER · Prevention of Future Deaths report

On 21st February 2014 I commenced an investigation into the death of THOMAS PATRICK MAHER dob 5th March 1928. The investigation concluded on the 4th June 2014 and the conclusion was one of ACCIDENTAL DEATH. The medical cause of death was 1a Chest Sepsis 1b Hospital Acquired Pneumonia 1c Left Acetabulum fracture of the hip 11 Alzheimer’s Disease, old age, atrial fibrillation, chronic anaemia and CVA.

On the 3rd of February 2014 whilst he was a patient at Trafford General Hospital, Mr Maher fell whilst on the ward and later alia fractured his acetabulum.

1. All the nursing notes, observation charts and pressure ulcer charts for the period 20th December 2013 to 29th January 2014 are missing, and despite a widespread search by the hospital, it has proved impossible to locate them. This had the effect of hampering the High Level Investigation and potentially the inquest itself.

2. On a number of occasions during his stay in the hospital, the falls risk assessment and the bed rails assessment were not updated per policy.

3. As a result of his perceived propensity to fall and to get out of bed, Mr Maher had a TAB alarm attached. It subsequently transpired that when he fell and broke his pelvis, this alarm had been removed and placed on his bed. If this were removed by a member of staff, then this would indicate a potentially negligent act; if removed by the patient then surely the alarm should activate to show that it is no longer offering protection.

4. On or around the 3rd February, a discussion took place between the treating doctor at Trafford and an orthopaedic specialist at MRI, during which it was agreed that a bed was available at MRI and that Mr Maher would be transferred. The ambulance was ordered to transport him and Mr Maher was taken and placed in the vehicle. In fact it then transpired that there was no bed available so he had to be taken from the vehicle and returned to the ward at Trafford General.
In the course of his evidence to me, the consultant Physician stated “we have major problems getting patients transferred to MRI and other hospitals, we frequently have to wait 3 or 4 days for transfer of a patient who should have gone immediately”. He then went on to state that in his opinion the ability to transfer patients between divisions of the same trust should be ‘second to none’ and in fact it is less than adequate.

5. On returning to the ward the doctors had prescribed oral morphine but the nursing staff were not trained/confident in giving this so the prescription had to be altered to oral morphine.

6. On the 5th February 2014 ████████ elderly care consultant, read Mr Maher’s notes and said that the complex discharge ward was not the appropriate place for Mr Maher to be and that he should be transferred to a medical or orthopaedic ward. Why was he on the inappropriate ward in the first place?

7. After he sustained the fall in hospital, there was a delay of almost four hours before his next of kin was informed.

8. There is an apparent major problem with regard to patient notes where those at MRI are ‘paper based’ whereas those at Trafford are electronic. I was told that it will be at least two years before this situation is reconciled. This is inherently dangerous in that the treating doctors may not have the up to date notes available to them. Both senior doctors who gave evidence to me described the system of transfer of notes between hospitals as “impossible”.