Source · Prevention of Future Deaths

Margaret Burman

Ref: 2024-0203 Date: 17 Apr 2024 Coroner: David Ridley Area: Wiltshire and Swindon Responses identified: 2 / 2 View PDF

Hospital wards lack adequate staffing for falls prevention, particularly for high-risk patients, exacerbated by bed blocking from medically stable patients awaiting community care, leading to an increased risk of falls.

Date 17 Apr 2024

56-day deadline 10 Jun 2024

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health)) falls in the hospital environment do happen, however, I was of the view in Avril's case that had there been an appropriate Healthcare Assistant present then Avril's fall and death more likely than not would have been avoided. During the course of the Inquest, I heard evidence from the Hospital's Falls Specialist, who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls . She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall . Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover. As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards. Especially where patients have conditions such as Dementia and Alzheimer's it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death. The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards. The longer they remain on the wards the Qreater the risk of falls especially if they are medically stabilised when in such Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl IDP

---- circumstances, they are more likely to be mobile. I asked as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge. As I indicated in Mr Eggleton's Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures. The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money. The commitment to provide 5000 extra "core" beds to deal with increasing demand is only going to add to the concern unless this issue is addressed. As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtably has a crucial and essential role to play.

Responses

2 respondents

NHS England NHS / Health Body

17 Apr 2024 PDF

Action Planned

NHS England highlights existing national guidance on falls risk assessment and prevention, including NICE guidelines, and states that regional colleagues will engage with the Bath and North East Somerset, Swindon and Wiltshire System to ensure local leadership is embedding national guidance and best practice. (AI summary)

View full response

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Margaret Avril Burman who died on 13 July 2021.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 17 April 2024 concerning the death of Margaret Avril Burman on 13 July 2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Margaret’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Margaret’s care have been listened to and reflected upon. 

Your Report raises concerns over appropriate staffing falls mitigation measures on wards occupied by people at risk of falls, in particular patients with dementia or Alzheimer’s Disease, and that there should be ‘national leadership and a standardised toolkit when assessing falls risks on hospital wards’ and that there should also be a greater degree of sharing of learning.

National leadership has already developed national guidance based on evidence- based practice which include falls risk assessment and toolkits to support implementation of appropriate interventions. At the time of Margaret’s admission to hospital in 2021, there was existing guidance available to support best practice around patients at risk of falls.

The National Institute for Health and Care Excellence (NICE) CG161 guidelines were first published in 2013 and cover assessment of fall risk and interventions to prevent falls in people aged 65 and over. The guidelines include recommendations on:

• multifactorial risk assessment of older people who present for medical attention because of a fall, or report recurrent falls in the past year
• multifactorial interventions to prevent falls in older people who live in the community
• multifactorial risk assessment of older peoples’ risk of falling during a hospital stay. This multifactorial assessment includes assessment of someone’s cognitive impairment.
• multifactorial interventions to prevent falls in inpatients at risk of falling.

The following guidance was also freely available in 2021:

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

10 June 2024

• The Fallsafe Project care bundle Fallsafe | British Geriatrics Society (bgs.org.uk), (2018)
• Falls and fractures: applying All Our Health - GOV.UK (www.gov.uk), (2015)
• Preventing falls in older people (nice.org.uk) for people at home (2013). Guidance and resources to support best practice is also readily available and was available during 2021. As well as the NICE guidance referenced above, the following national resources were also available:
• NHS England » Development of the ‘Avoiding Falls Level of Observation Assessment Tool’ in the NHSE Atlas of Shared Learning, (2019)
• Falls and fractures: applying All Our Health - GOV.UK (www.gov.uk), (2015) Since 2021, the British Geriatrics Society were also involved in developing the World Guidelines for Falls Prevention and Management for Older Adults: A Global Initiative1 published in 2022. These include a chapter on Falls in hospitals that conditionally recommends performing a multifactorial falls risk assessment in all hospitalised older adults >65 years of age. Regarding staffing levels, the headcount for registered nurses and support staff has increased over the last decade,2 however difficulties do remain in ensuring appropriate levels of staffing, especially to cover wards where patients are at risk of falls. Local nurse leaders are responsible for calculating safe levels of staffing using the Safer Nursing Care Tool - Shelford Group and Boards for NHS Trusts have been required to report on their staffing levels to NHS England on a six-monthly basis since 2014. As part of our response to the ongoing challenges around workforce, we published the NHS Long Term Workforce Plan June 2023, which sets out our plans to increase, train, retain and reform the NHS workforce over the next fifteen years. Your Report also raises a concern around patients medically fit for discharge are remaining in hospital due to a lack of appropriate community care being available. This remains a challenge for the NHS and social care services across England. As a key part of NHS England’s Urgent & Emergency Care recovery, NHS England together with colleagues across the DHSC and the Department for Levelling up, Housing and Communities (DLUHC) are focussed on improving discharge processes and capacity modelling to ensure the right number of commissioned beds/non-bedded care. A range of programmes aimed at improving both admissions avoidance and discharge flow is being undertaken to support the reduction in the number of patients in acute medical beds with no criteria to reside. This work is a key priority for the NHS and is being driven through the published NHS Operational Planning Guidance and the Better Care Fund planning process and has associated improvement support available to regions and local systems.

1 https://www.bgs.org.uk/wfg 2 NHS Digital, 2024. NHS Workforce Statistics, January 2024 England and Organisation.xlsx (live.com)

There is statutory guidance available on how health and care systems should support the safe and timely discharge of people who no longer need to stay in hospital: Hospital discharge and community support guidance - GOV.UK (www.gov.uk). Following review of Margaret’s care and your Report, my regional colleagues in the South West will be asked to engage with the Bath and North East Somerset, Swindon and Wiltshire System to seek assurance that local leadership is embedding national guidance and best practice. I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Department of Health and Social Care Central Government

3 Jul 2024 PDF

Action Taken

DHSC notes that NHS England is responding to the report and highlights NICE guidelines and Royal College of Physicians guidance on falls prevention. They mention actions taken by Salisbury NHS Foundation Trust since the death, including an improvement programme to reduce falls, additional activities for patients at risk, and improved assessments on admission. (AI summary)

View full response

Dear Mr Ridley,

Thank you for the Regulation 28 (Preventing Future Deaths) report of 17th April 2024 in relation to the death of Margaret Avril Burman. I am replying as Minister with responsibility for dementia. Please accept my apologies for the delay in responding to this matter.

Let me begin by saying how saddened I was to read about the circumstances of Ms Burman’s death. I would like to offer my sincere condolences to her family and loved ones. It is vital that we learn from incidents where we can in order to improve patient safety.

Your report raises several important issues, including appropriate staffing levels and falls mitigation in wards with people at risk of falls, in particular patients with dementia or Alzheimer’s Disease. It also refers to the need for a standardised toolkit when assessing the risk of falls on hospital wards coupled with greater sharing of learning from good practice across Trusts.

I am aware that that the National Medical Director is responding to your report on behalf of NHS England and as such I do not intend to duplicate the contents of his communication with you. However, I am assured that NHS England have reflected upon the concerns raised in your report in relation to Ms Burman’s care. 

NHS England advise that the risk of falls is an ongoing priority for providers and continues to be an active area of developing research and evidence. The current NICE guidelines Falls in older people: assessing risk and prevention describes evidenced based practice, including for healthcare and other professional and staff who care for older people who are at risk of falling. These guidelines are currently being updated and due to be published in March 2025. The Royal College of Physicians also provides evidenced based guidance on preventing falls and serious injury in Falls prevention in hospital.

I am informed that on 8 May 2024 a formal engagement meeting was held between the Care Quality Commission (CQC) and Salisbury NHS Foundation Trust at which your PFD report was discussed. The Director of Nursing acknowledged that pre-2021, Spire Ward referenced in your report had significant staffing problems, particularly around recruitment and retention. CQC was briefed on the actions taken by the Trust since the death of Ms Burman as follows:

 Improvement programme to reduce falls, including ‘bay watching’ and increase in staffing, specifically on Spire Ward. This includes ‘allocation on arrival’ for staff so that they can be allocated to wards, such as the Spire Ward, that are short staffed.  Additional activities for patients who are at risk of falls to improve sleep and therefore reduce activity throughout the night which could lead to a fall.  Improved assessment on admission to highlight patients at risk of falls.  Further education for staff on why understanding blood pressure measurements is critical, for instance that low blood pressure can lead to falls.  A ‘yellow’ blanket initiative is now embedded within the Emergency Department (where a patient might be at risk of falls, a yellow blanket is placed on the bed so that staff can easily recognise a patient who might fall if they begin to mobilise).

It is reassuring to know that there has been a reduction in falls at the Trust since 2021 and that CQC continue to engage with and monitor the Trust through their usual regulation and monitoring responsibilities.

I would like to thank you for bringing these important concerns to my attention.

Report sections

Investigation and inquest

On the 26th of July 2021, I opened an Inquest into the death of Margaret Avril Burman. During the course of the Inquest final hearing, I was told by the family that Margaret preferred to be known by her second name, Avril, and I will be referring to her by that second name for the remainder of this report. Avril died at Salisbury District Hospital here in Wiltshire on the 13th of July 2021. She was aged 88 years old. On the 5th of April 2024, I concluded Avril's Inquest. I found the medical cause of death was as follows: 1 a. lntracranial Bleed 1b. Head Injury 1c. Fall II. Dementia, Atrial Fibrillation (on Anticoagulation) I additionally recorded a short form conclusion of Accident and in response to the question as regards when, where and how (by what means Avril came by her death) I recorded in box 3 of the Record of Inquest as follows: "Margaret, who preferred to be known by her second name Avril, died on 13 July 2021 at Salisbury District Hospital in Wiltshire as a result of an intracranial bleed. Avril had an unwitnessed fall at around 2130 on the ward during the evening on 6 July 2021 resulting in the head injury. Avril had a history of falls pre-admission and had dementia. Avril also had atrial fibrillation and was on anticoagulation which was being given to her at the time of the fall despite doctors' directions that it be stopped, given on 30 June 2021 and 1 July 2021 . The Apixaban and the dementia more likely than not contributed to the severity of the bleed. The Falls Risk Assessment did not address the known falls risk which was high and there was no enhanced care documentation, although Avril was in a ward bay where but for the non-availability of a Health Care Assistant that shift, would have been present and more likely than not would have avoided the severity of the injury by managing the fall." Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl lDP

Circumstances of the death

Avril had a history of falls and was admitted briefly to Salisbury District Hospital on the 26th of June 2021 having had what was believed to have been an unwitnessed seizure. She was discharged the following day but then re-attended and was subsequently re-admitted on the 28th of June 2021 following a fall and possible long lie. There was concern that Avril had a urinary tract infection and she was prescribed appropriate antibiotics. Avril was also in receipt of Apixaban for atrial fibrillation and although there are notes on 2 occasions where a doctor has directed that the medication be stopped, however, this did not appear to happen before she was found having fallen on the ward on the 6th of July 2021. As you will be able to see from what I have recorded in relation to the when, where and how in box 3 of the Record of Inquest, relevant risk assessment falls were not appropriately completed by nursing staff although I did accept evidence that Avril had been placed in a bay with a small number of other patients on Spire Ward with the intention that overnight there would be a Healthcare Assistant who would monitor specifically those patients in that bay and assist any patient who was found out of bed to either return to bed or for example be supported and assisted to the lavatory. Unfortunately, especially back in 2021 I heard that there were significant staffing issues with staff off sick because of COVID and challenges in relation to temporary staff unwilling to provide additional support. As a consequence, the Healthcare Assistant was unavailable, and no replacement was secured for the overnight shift and consequently there was no person able to monitor the ward bay where Avril's bed was located. Her fall was unwitnessed by staff and as a consequence of her fall, she sustained a traumatic head injury from which she died on the 13th of July 2021. CORONER'S CONCERNS As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health)) falls in the hospital environment do happen, however, I was of the view in Avril's case that had there been an appropriate Healthcare Assistant present then Avril's fall and death more likely than not would have been avoided. During the course of the Inquest, I heard evidence from the Hospital's Falls Specialist, who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls . She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall . Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover. As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards. Especially where patients have conditions such as Dementia and Alzheimer's it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death. The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards. The longer they remain on the wards the Qreater the risk of falls especially if they are medically stabilised when in such Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl IDP

---- circumstances, they are more likely to be mobile. I asked as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge. As I indicated in Mr Eggleton's Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures. The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money. The commitment to provide 5000 extra "core" beds to deal with increasing demand is only going to add to the concern unless this issue is addressed. As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtably has a crucial and essential role to play.

Inquest conclusion

"Margaret, who preferred to be known by her second name Avril, died on 13 July 2021 at Salisbury District Hospital in Wiltshire as a result of an intracranial bleed. Avril had an unwitnessed fall at around 2130 on the ward during the evening on 6 July 2021 resulting in the head injury. Avril had a history of falls pre-admission and had dementia. Avril also had atrial fibrillation and was on anticoagulation which was being given to her at the time of the fall despite doctors' directions that it be stopped, given on 30 June 2021 and 1 July 2021 . The Apixaban and the dementia more likely than not contributed to the severity of the bleed. The Falls Risk Assessment did not address the known falls risk which was high and there was no enhanced care documentation, although Avril was in a ward bay where but for the non-availability of a Health Care Assistant that shift, would have been present and more likely than not would have avoided the severity of the injury by managing the fall." Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury, Wiltshire, SPl lDP

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2024-0203
Date of report: 17 April 2024
Coroner: David Ridley
Coroner area: Wiltshire and Swindon

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Jun 2024.

Sent to

Department of Health and Social Care

NHS England

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.