Mrs Elizabeth Ann Cox · Prevention of Future Deaths report

On 17 November 2014 I commenced an investigation into the death of Mrs Elizabeth Ann Cox, aged 84. The investigation concluded at the end of the inquest on 11 March 2015. The conclusion of the inquest was Accident. The cause of death was :

1a subdural haemorrhage
1b Fall

2 Rheumatoid arthritis, myeloproliferative disorder, previous subdural haemorrhages, epilepsy, dementia, postural hypotension.

As is evident from the cause of death, Mrs Cox had a number of co-morbidities. She had suffered earlier falls, including previous falls whilst an in-patient of the trust on 14 June 2014 and 9 July 2014.

Mrs Cox’s final admission to Kingsmill Hospital was on 8 July 2014, after suffering a fit. She was admitted to ward 42 on 11 July 2014. The evidence showed that she was risk-assessed for falls, and it was clear that she was at high risk. Mrs Cox had a history of stroke, previous falls and SDHs, fits, postural hypotension, dementia, mobility problems, poor eyesight and was aged 84.

It was accepted in evidence that this assessment should have resulted in Mrs Cox being nursed in a Hi-Lo bed and crash mats being provided. This equipment was not put in place.

Mrs Cox suffered a fall from her bed in the early hours of 18 July 2014. The fall was unwitnessed, although later investigations revealed that Mrs Cox had been trying to get out of her bed to go to the toilet as she had loose stools. Although she had a buzzer, she was not able to use this.

Mrs Cox’ condition deteriorated significantly after this fall, and she died at Kingsmill Hospital on 10 August 2014. I found there was a clear link between the fall on 18 July 2014 and her death.

The evidence of senior nursing staff involved with this ward and with the trust’s internal investigation made it clear that those working on the ward on the night of 17/18 July felt they needed further staff to cope with the demands of the patients they were looking after.

We heard that the ward sister followed hospital protocol to request assistance. When it was clear that no one was available from neighbouring wards, a bank nurse was requested. Unfortunately, the bank nurse cancelled at very short notice. The duty nurse manager was called, but noone was available to assist at short notice.

1. During daytime hours, where additional staff are needed, the Reducing Harm Team can be contacted to provide the necessary resources. I was told, although this is currently under review, that,as matters stand, this (or an equivalent) is not available during the night.
2. It has been suggested as part of a trust-wide review that the number of staff available on the wards at night be reduced – from 3 registered and 2 unregistered currently, to 3 registered and 1 unregistered. I am aware that this is merely a proposal – and not currently in place – but should this come into effect, I am concerned that events like these may re-occur, where staff simply do not have the capacity to look after their patients safely, because of workloads.