Source · Prevention of Future Deaths
Robert Payne
Ref: 2015-0140
Date: 16 Apr 2015
Coroner: Andrew Barkley
Area: Powys, Bridgend & Glamorgan Valleys
Responses identified: 0 / 2
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Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.
Date
16 Apr 2015
56-day deadline
11 Jun 2015 est.
Responses identified
0 of 2
Coroner's concerns
Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.
View full coroner's concerns
and July May May: May
(1) Despite repeated falls risk assessments identifying the deceased as being at high risk of falling he fell on no less than four occasions whilst in hospital which necessitated further surgery as a direct consequence of the fall on the 20" May 2014 (2) He was transferred between wards at Iam in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.
(1) Despite repeated falls risk assessments identifying the deceased as being at high risk of falling he fell on no less than four occasions whilst in hospital which necessitated further surgery as a direct consequence of the fall on the 20" May 2014 (2) He was transferred between wards at Iam in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed.
Report sections
Investigation and inquest
On the 23rd 2014 commenced an investigation into the death of Robert Henry Payne, investigation concluded at the end of an inquest on today's date which is the 14th April 2015_ The conclusion of the inquest was a narrative conclusion "Robert Henry PAYNE died as a result of infection which he suffered having undergone surgery to repair a fractured neck of femur which he sustained in a fall at his home address on gth May 2014 and which required further surgery aS & result of & further fall and dislocation which he sustained whilst in hospital"
Circumstances of the death
The deceased was admitted to the Princess of Wales Hospital in Bridgend on the 9th 2014 having fallen at his home address and fractured his left neck of femur; The femur was repaired on the 9 May 2014 and he was managed on the ward. He fell on the ward; not sustaining any injury on the 12th May and again on the 17h He was transferred between two wards in the small hours of 20th and within hours fell again dislocating the hip which had been repaired, This necessitated further surgery and it became apparent that the surgical wound had become infected. He had one further fall on the 2nd June whilst in the care of physiotherapists. His condition deteriorated and he passed away on the 13lh July.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action
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Report details
- Reference
- 2015-0140
- Date of report
- 16 April 2015
- Coroner
- Andrew Barkley
- Coroner area
- Powys, Bridgend & Glamorgan Valleys
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: 11 Jun 2015 (estimated).
Sent to
- Abertawe Bro Morgannwg University Health Board
- Health Inspectorate Wales