Source · Prevention of Future Deaths

Maureen Martin

Ref: 2019-0220 Date: 26 Jun 2019 Coroner: Andrew Haigh Area: Staffordshire South Responses identified: 1 / 1 View PDF

The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.

Date 26 Jun 2019

56-day deadline 8 Nov 2019 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.

View full coroner's concerns

The MATTER OF CONCERN is as follows_ Mrs Martin's family were very pleasant and extremely gracious about the circumstances of her death Her son pointed out that at the time of her fall, the desk for the Nurses' Station on the ward was facing the wrong way: Possibly this was linked to some temporary decoration works_ When Mrs Martin's son mentioned this, the desk was repositioned appropriately. would be grateful if you could check that the desks at Nurses" Stations in Queens Hospital are properly positioned and, if they do temporarily have to be moved, that the best possible visibility is maintained.

Responses

1 respondent

University Hospitals of Derby and Burton NHS Trust NHS / Health Body

12 Aug 2019 PDF

Action Taken

The Trust removed the nursing station desk on Ward 5 and provided staff with a "desk on wheels" to improve visibility. A walkaround review has been undertaken of all of the nursing stations/desks at Queens Hospital Burton and they are all positioned correctly. (AI summary)

View full response

Dear Sir RE: Regulation 28 Report following the inquest touching upon the death of Maureen Martin am in response to your Regulation 28 Report dated 28 March 2019 following the inquest touching upon the death of Maureen Martin_ During the inquest understand the lady's family raised a concem that at the time of Mrs Martin's fall on Ward 5, the Nursing Station was facing the wrong way, possibly because there was some temporary decoration works being caried out: Mrs Martin's son highlighted that when this was pointed out to the nursing staff steps were taken to move the nursing station desk to a more appropriate position: You have therefore, cuite properly, asked for the Trust to check that the desks at each nursing station in Queen's Hospital are properly positioned and, if do temporarily have to be moved_ that the best possible visibility is maintained. would like to begin by offering an assurance that the Trust has taken urgent steps to address your concems as follows: Mrs Martin's fall on Ward 5 was the subject of an internal investigation which concluded that the nursing station was indeed moved and it was found not to promote visibility of the patients as the nurse, if sat at the station, was facing the incorrect way: The action that arose out of this investigation was to remove the nursing station desk on that Ward and provide the staff with "desk on wheels" so that this can be wheeled with the staff as walk around the

Chairman: John Rivers CBE DL

Chief Executive; Gavin Boyle writing they they Bays.

2_ A walkaround review has also been undertaken of all of the nursing stationsldesks at Queens Hospital Burton to see if are positioned in the correct places. would like to assure you that are all in the correct places and are the correct way. Indeed, most of the nursing desks are on wheels to allow nurses to complete their paperwork whilst they are in the Bays caring for patients; this encourages more visibility of the nursing staff and allows more time for the nurses to be with patients trust that you will be satisfied and assured that the desks are in the correct places ad promote visibility for the safety of our patients. Please do not hesitate t2 let me know if you require any further information from the Trust

Report sections

Investigation and inquest

On 25 April 2019 | commenced an investigation into the death of Maureen Veronica Martin 88 years. The investigation concluded at the end of the inquest on 26 June 2019. The conclusion of the inquest was 'accident' with the cause of death being 'subdural haematoma'. CIRCUMSTANCES OF THE DEATH Maureen Martin was admitted to Queens Hospital on 10th April 2019 with cardiac problems_ In the early hours of 14th April, while attempting to mobilise by herself on the ward, she fell and sustained a severe head injury: This was not suitable for surgery and it led to her death at the hospital on 19t6 April. CORONER'S CONCERN During the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows_ Mrs Martin's family were very pleasant and extremely gracious about the circumstances of her death Her son pointed out that at the time of her fall, the desk for the Nurses' Station on the ward was facing the wrong way: Possibly this was linked to some temporary decoration works_ When Mrs Martin's son mentioned this, the desk was repositioned appropriately. would be grateful if you could check that the desks at Nurses" Stations in Queens Hospital are properly positioned and, if they do temporarily have to be moved, that the best possible visibility is maintained. ACTION SHOULD BE TAKEN aged

In my opinion action should be taken to prevent future deaths and believe you or your 'organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by Monday 26" August 2019 I, the coroner, may extend the period: Your response must contain details of action taken or proposed to be taken, setting out the timetable for action: Otherwise you must explain why no action is proposed COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mrs Martin's family Aviva Life Services UK Limited Scottish Widows Unit Trust Managers Limited am also under a duty to send the Chief Coroner a copy of your response The Chief Coroner may publish either or both in a complete or redacted or summary form: He may send copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. h k Andrew A Haigh HM Senior Coroner for Staffordshire (South) Coroner's Office No 1 Staffordshire Place Stafford ST16 2LP Tel No: 01785 276127 sscor@staffordshire gov.uk

Circumstances of the death

Maureen Martin was admitted to Queens Hospital on 10th April 2019 with cardiac problems_ In the early hours of 14th April, while attempting to mobilise by herself on the ward, she fell and sustained a severe head injury: This was not suitable for surgery and it led to her death at the hospital on 19t6 April.

Action should be taken

aged

In my opinion action should be taken to prevent future deaths and believe you or your 'organisation have the power to take such action.

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Shared signals

Report details

Reference: 2019-0220
Date of report: 26 June 2019
Coroner: Andrew Haigh
Coroner area: Staffordshire South

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Nov 2019 (estimated).

Sent to

University Hospitals of Derby and Burton NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.