John Edward Stiff · Prevention of Future Deaths report

On 1 December 2022 I commenced an investigation into the death of John Edward Stiff. The investigation concluded at the end of the inquest on the 5 April 2023. The conclusion of the inquest was that Mr Stiff died as a result of an accident (following a fall).

On the 10 November 2022, Mr. Stiff was admitted to Queen's Hospital having suffered a believed unwitnessed fall. In Queen's Hospital, he was diagnosed as suffering from an undisplaced fracture of the pelvis. A decision was taken to treat Mr. Stiff conservatively. Even though there was no surgical intervention, he was admitted under the care of the orthopaedic team. The orthopaedic team are not specialists in controlling medical problems associated with fractures. During the course of the admission, Mr. Stiff's appetite was much reduced. He was not offered any nutritional supplements. On the 15 November 2022 he had reduced oxygen saturations and the medical team became involved in his care. He was diagnosed as suffering from a chest infection. He was treated with supplemental oxygen; intravenous fluids and intravenous antibiotics. Sadly, Mr. Stiff did not recover and he passed away at Queen's Hospital on the 16 November 2022. It is likely that the fall and fractured pelvis on the 10 November 2022 caused a decline in health and mobility which would have contributed to the development of the fatal pneumonia.

The Inquest heard evidence from an orthopaedic surgeon that patients such as Mr Stiff, who suffer hip and pelvic fractures and who have a number of additional age-related co-morbidities, would be best cared for by ortho-geriatricians. The inquest heard that this matter has been raised by the orthopaedic team on multiple occasions, but the orthogeriatric provision has not been increased.

The Inquest also heard that the lack of orthogeriatric provision is a national issue of concern within the NHS.

Orthopaedic trauma in elderly patients often exacerbates underlying medical conditions. Orthogeriatric trained staff would be better trained to recognise and treat medical co-morbidities. It is therefore considered that improved access to orthogeriatric care for this patient cohort could prevent future untimely deaths.