Source · Prevention of Future Deaths
William Bergman
Ref: 2017-0343
Date: 31 Oct 2017
Coroner: ME Hassell
Area: London Inner (North)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified concerns regarding a staff nurse's assessment and management of a head injury, noting the absence of immediate observations, a medical review, and recognition of potential serious consequences for an elderly patient with existing health conditions.
Date
31 Oct 2017
56-day deadline
1 Apr 2018 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The coroner identified concerns regarding a staff nurse's assessment and management of a head injury, noting the absence of immediate observations, a medical review, and recognition of potential serious consequences for an elderly patient with existing health conditions.
View full coroner's concerns
The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine.
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick.
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence.
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way.
Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick.
She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review.
She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence.
When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan.
She completed a Datix report only the following day, after Mr Bergman’s death.
The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing.
The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way.
Report sections
Investigation and inquest
On 29 December 2016, one of my assistant coroners, Sarah Bourke, commenced an investigation into the death of William Bergman, aged 88 years. The investigation concluded at the end of the inquest earlier today. The jury made a narrative determination, which I attach.
Circumstances of the death
Mr Bergman, who suffered with vascular dementia, was admitted to the Royal London Hospital and diagnosed with pneumonia. He died following an impact to his forehead sustained while healthcare assistants were changing him on 19 December 2016, variously described as hitting it on the cot side or on the side of the nearby television. His deterioration was noted several hours after the incident, and when he was then scanned, he was found to have sustained a subdural haematoma and a massive intracranial bleed.
Copies sent to
Care Quality Commission for England
Similar PFD reports
Report details
- Reference
- 2017-0343
- Date of report
- 31 October 2017
- Coroner
- ME Hassell
- Coroner area
- London Inner (North)
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: 1 Apr 2018 (estimated from the Judiciary.uk publication date).
Sent to
- Barts Hospital NHS Trust