John Lambton

On August 2017 Mr John Thomas Lambton; known as Tom, 88 years, died at Sunderland Royal Hospital. The Inquest, as part of my Investigation, concluded on 13th February 2018, when [ recorded a conclusion of Accident The Cause of Death following Post-Mortem Examination was: Ia Brain Herniation Ib Raised Intracranial Pressure Ic Subdural Haematoma II Dementia and Warfarin Therapy

Tom was admitted to Sunderland Royal Hospital on the 8th of August 2017 following a series of unwitnessed fallslincidents over several whilst in respite care at Dairy Lane Care Centre. Subsequent radiological Investigations revealed he had sustained a fractured neck of femur (NOF) and had an active subdural haemorrhage. On the morning of Saturday the 5th of August Tom was noted to have a bump to his head. On the evening of Sunday the 6'h of August Tom was noted to be asleep in his room: At 8.45 PM he was found lying on the floor between his bedroom and en suite bathroom Tom was assisted back to his bed by care staff and he requested an ambulance. At lunch time on Monday the 7ih of August the GP attended Dairy Lane and examined Tom: On Tuesday the 8'h of August at 11.20AM Tom arrived to hospital by ambulance. Tom underwent surgical repair of his NOF fracture, which was uneventful, the subdural haemorrhage was managed conservatively with close monitoring and reversal ofhis warfarin anticoagulation. He appeared clinically stable for over a week, repeat scans showed no change in the size of the subdural haematoma and he was treated for a minor Civic Centre; Burdon Road, Sunderland, SR2 7DN Tel 0191 5617843 Fax 019[ 5537803 WWW.sunderlandcoroner co.uk Dairy Lane 27th aged OF days urinary tract infection and delirium He deteriorated rapidly 18 days post admission with reducing conscious level and episodes of apnoea, attributed to a subdural re-bleed, and subsequently died on 27h August 2017.

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action: