Source · Prevention of Future Deaths
Elaine Giles
Ref: 2014-0529
Date: 5 Dec 2014
Coroner: ARW Forrest
Area: South Lincolnshire
Responses identified: 0 / 1
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An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed home environment assessment and ensured adequate post-discharge support.
Date
5 Dec 2014
56-day deadline
30 Jan 2015 est.
Responses identified
0 of 1
Coroner's concerns
An inaccurate pre-discharge assessment of a patient's functional ability, particularly with stairs, highlighted the need for more detailed home environment assessment and ensured adequate post-discharge support.
View full coroner's concerns
_ Whilst assessed as "safe" on stairs prior to discharge from Peterborough Hospital, it is very clear that Elaine could not negotiate stairs safely when she got home: This tragic case draws attention to the need for detailed assessments of a patient's likely functional performance in their home circumstances after discharge and the importance of ensuring adequate support is available in the home environment.
Report sections
Investigation and inquest
On 2gih May 2014 commenced an investigation into the death of Elaine Marilyn GILES, age 66. The investigation concluded at the end of the inquest on 4th December 2014 The conclusion of the inquest was ACCIDENT .
Circumstances of the death
Elaine was a generally fit 66 year old woman who fractured her left neck of femur in a minimal trauma fall at work: She had an uneventful operation with the insertion of a prosthetic hip. She required 10 of post-operative care in hospital before discharge Her care was complicated by recurrent nausea, difficulty in pain control, dizziness, feeling faint; and swollen feet. This all interfered with her rehabilitation. Evidence was presented at the inquest that she had been pronounced "safe' walking with an aid and "safe" on stairs Once at home it became clear that Elaine was not "safe" on her stairs at home_ The problems she had included foot swelling to the extent that her slippers did not fit securely. 5 days after her return home she fell whilst descending the stairs_ There were no obvious signs of injury but she took more than a minute or two to recover. She Unit 1, Gilbert Drive, Endeavour Park, Boston PE21 7TQ Tel: 01522 553374 Fax: 01522 516717 Email: HMCoroner_Southlincolnshire@lincolnshire gov.uk for days
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire had a telephone conversation at Spm that evening; but was found dead at Ipm the following day: Whilst it is difficult to estimate the time of death with any precision it is likely that she died about 12 hours or so before she was found: The cause of death at post mortem was fat embolism. The likely cause of the fat embolism was jarring of her hip joint prosthesis in the fall. Forcing fatty material from her bone marrow into the systemic circulation_
A RW Forrest LLM, FRCP, FRCPath GMC Number: 1333523 Her Majesty's Senior Coroner for South Lincolnshire had a telephone conversation at Spm that evening; but was found dead at Ipm the following day: Whilst it is difficult to estimate the time of death with any precision it is likely that she died about 12 hours or so before she was found: The cause of death at post mortem was fat embolism. The likely cause of the fat embolism was jarring of her hip joint prosthesis in the fall. Forcing fatty material from her bone marrow into the systemic circulation_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you andlor your organisation have the power 'to take such action:
Copies sent to
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Report details
- Reference
- 2014-0529
- Date of report
- 5 December 2014
- Coroner
- ARW Forrest
- Coroner area
- South Lincolnshire
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: 30 Jan 2015 (estimated).
Sent to
- Peterborough and Stamford NHS Trust