Published: 17:13, 15 April 2014 |
A fall that caused the death of a pensioner at Maidstone Hospital could have been avoided, a coroner has ruled.
Sheila Acott, 67, of Old Tovil Road, Maidstone, died on February 14 last year after falling and injuring her head near the nurses' station on Foster Clark ward.
After a two-day hearing, Mid Kent and Medway coroner Patricia Harding recorded a verdict of accidental death.
But after hearing evidence from the doctors and nurses involved in the care of Mrs Acott, who had been admitted to hospital two weeks earlier for a different problem, the coroner said she was satisfied that if the nursing staff had known of Mrs Acott's high risk of falls, it could have been avoided.
Mrs Acott had been suffering from multiple medical problems - including kidney disease, vertigo, aspergillius of the thalamus (fungal spores affecting the brain), arthritis and myelodysplasia (a malignant blood disorder).
Although she had been ill for two years, she had been able to live at home with her husband Ronald caring for her. However, she had to be helped in and out of bed and could only walk with a frame.
She was admitted to Maidstone Hospital on January 28 in a confused state and treated for an infection.
In the early hours of Wednesday, February 13, she managed to get out of bed unaided and walked to the nurses station without her zimmer frame. While standing at the nurses' station, she suddenly fell backwards and hit her head, cutting it.
A doctor was called and stitched the wound, but she was not given a CT scan to check if there were internal injuries as she appeared to be stable.
At 11am the next day, she suddenly became unresponsive and began bleeding from the mouth and nose.
The hospital then performed a CT scan, which showed a massive brain haemorrhage caused by the fall and the neurosurgeons advised that nothing could be done for her. She died that evening.
During the inquest, it emerged staff at the hospital had failed to complete a care plan for Mrs Acott.
Giving evidence, ward manager Hilary Bulmer admitted sections of the care plan had not been completed and that no manual handling assessment was done.
Miss Bulmer, who later had conducted an internal review for Maidstone and Tunbridge Wells NHS Trust, was questioned by the coroner on her report that implied the assessments had been done.
She admitted her report had been misleading.
Mrs Acott's daughter Nicola Davies said: "Mum suffered a terrible fall when she was under the care of the hospital which should never have happened if she had been properly looked after.
"Losing mum has been devastating for the whole family and we hope that what happened to her will raise awareness and help improve hospital standards, particularly regarding patients' risk of falls, so that other families are spared the ordeal that we have been through."
The coroner ordered the Maidstone and Tunbridge Wells NHS Trust to provide her with a report within 28 days outlining the steps it had taken to prevent hospital falls in future.
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