Source · Prevention of Future Deaths
Harold Blackshaw
Ref: 2021-0292
Date: 2 Sep 2021
Coroner: Emma Serrano
Area: Stoke-on-Trent & North Staffordshire Coroner’s Court
0 responses identified · 2 indexed addressees
View PDF
AI-generated concerns summaryThe coroner raised concerns about the lack of an admission process at Haywood Hospital's Grange Ward to assess the needs of patients, particularly those at high risk of falls, and to implement appropriate preventative measures.
Date
2 Sep 2021
56-day deadline
29 Oct 2021
stated in the report
Responses identified
0 of 2
Coroner's concerns
The coroner raised concerns about the lack of an admission process at Haywood Hospital's Grange Ward to assess the needs of patients, particularly those at high risk of falls, and to implement appropriate preventative measures.
View full coroner's concerns
During the course of the inquest evidence was given regarding the admission process for patients admitted to the Haywood Hospital. Specifically the rehabilitation ward which Mr Blackshaw was admitted to (“Grange Ward”). It was heard that this ward was primarily for the rehabilitation of elderly patients that were recovering from injuries; some after falls. Some patients were high risk of falls. The evidence given suggested that there was no admission process which assessed the needs of each patient and what measures should be put in place to meet their needs, before they came to the ward, or when they were on the ward. This gives me concern that a future death could result.
Report sections
Investigation and inquest
On 04/03/2021 I commenced an investigation into the death of Harold Blackshaw, aged 72. The investigation concluded at the end of the inquest on 6th August 2021.
The conclusion of the inquest was Harold Blackshaw, who passed away on the 1 March 2021, at Trentham House Nursing Home, Chivelstone Grove, Trentham, Stoke-on-Trent, from COVID-19 had a past medical history of falls and Parkinson’s disease. On the 12 December 2020 he fell at his home address and sustained a right fractured neck of femur. He was admitted to the Royal Stoke University Hospital, Stoke-on-Trent and received a hemiarthroplasty. His hip dislocated once on the 5 January 2021 after he fell at a care home and once on the 17 January 2021 after he fell at the Haywood Hospital, Stoke-on-Trent. There was an opportunity to do a full falls risk assessment on his admission. This was not done. After both dislocations he required further surgery. After the final surgery he was discharged on the 27 January 2021 to Golden Gate Care Home. He contracted COVID 19 whilst resident here. He was further admitted to the Royal Stoke University Hospital on the 19 February 2021 after his health deteriorated. He was discharged to Trentham House Nursing Home for palliative care where he passed away on the 1 March 2021.
The medical cause of death was found to be 1a) Covid 19. II) Fractured neck of femur, Parkinson's Disease, rheumatoid arthritis, chronic obstructive pulmonary disease.
The conclusion of the inquest was Harold Blackshaw, who passed away on the 1 March 2021, at Trentham House Nursing Home, Chivelstone Grove, Trentham, Stoke-on-Trent, from COVID-19 had a past medical history of falls and Parkinson’s disease. On the 12 December 2020 he fell at his home address and sustained a right fractured neck of femur. He was admitted to the Royal Stoke University Hospital, Stoke-on-Trent and received a hemiarthroplasty. His hip dislocated once on the 5 January 2021 after he fell at a care home and once on the 17 January 2021 after he fell at the Haywood Hospital, Stoke-on-Trent. There was an opportunity to do a full falls risk assessment on his admission. This was not done. After both dislocations he required further surgery. After the final surgery he was discharged on the 27 January 2021 to Golden Gate Care Home. He contracted COVID 19 whilst resident here. He was further admitted to the Royal Stoke University Hospital on the 19 February 2021 after his health deteriorated. He was discharged to Trentham House Nursing Home for palliative care where he passed away on the 1 March 2021.
The medical cause of death was found to be 1a) Covid 19. II) Fractured neck of femur, Parkinson's Disease, rheumatoid arthritis, chronic obstructive pulmonary disease.
Circumstances of the death
Harold Blackshaw, who passed away on the 1 March 2021, at Trentham House Nursing Home, Chivelstone Grove, Trentham, Stoke-on-Trent, from COVID-19 had a past medical history of falls and Parkinson’s disease. On the 12 December 2020 he fell at his home address and sustained a right fractured neck of femur. He was admitted to the Royal Stoke University Hospital, Stoke-on-Trent and received a hemiarthroplasty. His hip dislocated once on the 5 January 2021 after he fell at a care home and once on the 17 January 2021 after he fell at the Haywood Hospital, Stoke-on-Trent. There was an opportunity to do a full falls risk assessment on his admission. This was not done. After both dislocations he required further surgery. After the final surgery he was discharged on the 27 January 2021 to Golden Gate Care Home. He contracted COVID 19 whilst resident here. He was further admitted to the Royal Stoke University Hospital on the 19 February 2021 after his health deteriorated. He was discharged to Trentham House Nursing Home for palliative care where he passed away on the 1 March 2021. .
Copies sent to
2. Trentham House Care Home3. Golden Hill Nursing Home4. University Hospital of North Midlands5. NG Healthcare
Similar PFD reports
Report details
- Reference
- 2021-0292
- Date of report
- 2 September 2021
- Coroner
- Emma Serrano
- Coroner area
- Stoke-on-Trent & North Staffordshire Coroner’s Court
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Oct 2021 (stated in the report).
Sent to
- Haywood Hospital
- NHS England