Source · Prevention of Future Deaths
Irene Fitches
Ref: 2022-0051
Date: 18 Feb 2022
Coroner: Jacqueline Lake
Area: Norfolk
0 responses identified · 1 indexed addressee
View PDF
AI-generated concerns summaryThe hospital's Falls Policy does not comply with NICE Guidelines, and a planned new policy, staff training, and the appointment of a Falls Lead have all been significantly delayed. The implementation of assisted technology for patient monitoring has also not progressed.
Date
18 Feb 2022
56-day deadline
14 Apr 2022
stated in the report
Responses identified
0 of 1
Coroner's concerns
The hospital's Falls Policy does not comply with NICE Guidelines, and a planned new policy, staff training, and the appointment of a Falls Lead have all been significantly delayed. The implementation of assisted technology for patient monitoring has also not progressed.
View full coroner's concerns
1. The present Falls Policy does not comply with NICE Guidelines.
2. Evidence was heard that a Falls Policy was drafted, and a Risk Assessment trialled at the beginning of 2020, the Covid-19 pandemic intervened and delayed its completion.
3. There is no person appointed as Falls Lead. The job application has not yet been advertised, although it is recognised that someone is required to lead the Falls process.
4. Staff will need training and the training package has not yet been developed.
5. Assisted Technology is being considered to alert staff to movements and the needs of patients. This has not been progressed since October 2021 and is still at an early stage.
2. Evidence was heard that a Falls Policy was drafted, and a Risk Assessment trialled at the beginning of 2020, the Covid-19 pandemic intervened and delayed its completion.
3. There is no person appointed as Falls Lead. The job application has not yet been advertised, although it is recognised that someone is required to lead the Falls process.
4. Staff will need training and the training package has not yet been developed.
5. Assisted Technology is being considered to alert staff to movements and the needs of patients. This has not been progressed since October 2021 and is still at an early stage.
Report sections
Investigation and inquest
On 26/07/2021 I commenced an investigation into the death of Irene Muriel FITCHES aged 77. The investigation concluded at the end of the inquest on 11/02/2022. The medical cause of death was: 1a) Subdural Haematoma 1b) Fall 1c) Benign Positional Paroxysmal Vertigo 1d) Type 2 Diabetes, Hypertension, Mild Cognitive Impairment The conclusion of the inquest was: Accident.
Circumstances of the death
Mrs Fitches had a significant past medical history. On 17 July 2021 Mrs Fitches was admitted to Norfolk and Norwich University Hospital due to dizziness, nausea and being generally unwell. Mrs Fitches was diagnosed with Benign Positional Paroxysmal Vertigo and a management plan was put in place. Mrs Fitches was considered medically fit for discharge. On 21 July 2021 Mrs Fitches had an unwitnessed fall in her room and suffered a head injury. Her condition deteriorated and she became unresponsive. Mrs Fitches died on 22 July 2021.
Copies sent to
Department of HealthCare Quality Commission (CQC)
Similar PFD reports
Report details
- Reference
- 2022-0051
- Date of report
- 18 February 2022
- Coroner
- Jacqueline Lake
- Coroner area
- Norfolk
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: 14 Apr 2022 (stated in the report).
Sent to
- Norfolk and Norwich University Hospital