Source · Prevention of Future Deaths
Anthony Wood
Ref: 2025-0282
Date: 3 Jun 2025
Coroner: John Taylor
Area: South London
Responses identified: 0 / 1
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A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when two were required.
Date
3 Jun 2025
56-day deadline
29 Jul 2025 est.
Responses identified
0 of 1
Coroner's concerns
A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when two were required.
View full coroner's concerns
(1) the patient was identified as at high risk of a fall (2) he was deemed to be severely frail (and hence at corresponding risk, if a fall were to occur) (3) there were no crash mats at the side of his bed (4) it was known that the patient had a propensity to push staff when being changed (5) the bed-rail was not up when the patient was attended by a HCA acting alone (6) that HCA was unable, on his own, to hold on to the patient, in order to prevent him from falling out of bed (7) the patient should have had the assistance of two members of staff, and not just one, when being prepared to be washed and changed All of these matters are recorded in the Trust's own Datix report.
Report sections
Investigation and inquest
On 4 October 2024, an investigation was commenced into the death of Anthony Haydn WOOD. The investigation concluded at the end of the inquest. The conclusion of the inquest was:
"Accident, to which inadequate safety measures (to guard against the risk of a fall from bed) contributed".
The medical cause of death
1a Intracranial Haemorrhage
1b Inpatient fall
"Accident, to which inadequate safety measures (to guard against the risk of a fall from bed) contributed".
The medical cause of death
1a Intracranial Haemorrhage
1b Inpatient fall
Circumstances of the death
The deceased was admitted to St. Helier Hospital on 1 September 2024. On 22 September 2024, he was to be changed and turned by the ward HCA. Whilst waiting for a second nurse / HCA to join, that HCA lowered the first bed-rail. The patient rolled towards the side of the bed and fell out onto the floor. He hit his head, and his left shoulder and hip. A CT scan of the head revealed contusion, a traumatic subarachnoid haemorrhage and an acute-on-chronic subdural haemorrhage. He was not suitable for neurosurgical intervention. He died, at the hospital, on 26 September 2024.
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Report details
- Reference
- 2025-0282
- Date of report
- 3 June 2025
- Coroner
- John Taylor
- Coroner area
- South London
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Jul 2025 (estimated).
Sent to
- Epsom and St. Helier University Hospitals NHS Trust
Non-response list
The Chief Coroner has confirmed the following did not respond within the required period:
- Epsom and St. Helier University Hospitals NHS Trust