William Bergman

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.