Source · Prevention of Future Deaths
Martin McCabe
Ref: 2014-0505
Date: 20 Nov 2014
Coroner: Andrew Barkley
Area: Powys, Bridgend & Glamorgan Valleys
0 responses identified · 1 indexed addressee
View PDF
AI-generated concerns summaryNo falls risk assessment was carried out upon the patient's admission to ward 15, with staff relying on an outdated assessment that did not include crucial information about recent falls and new medication.
Date
20 Nov 2014
56-day deadline
15 Jan 2015 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
No falls risk assessment was carried out upon the patient's admission to ward 15, with staff relying on an outdated assessment that did not include crucial information about recent falls and new medication.
View full coroner's concerns
_ (1) Upon his admission to ward 15 on the 11' September no risk assessment in relation to his risk of falling was carried out: Staff relied on a risk assessment which had previously been carried out 3 months before this admission and did not update it with relevant information such as a history of two falls whilst at home andalso the use of Dilwyn Dilwyn being_ day the night time sedation whilst on the ward; Both of these factors were accepted by the health board to be material factors in a risk assessment and which may well have had a bearing in the way in which staff dealt with him on the ward:
Report sections
Investigation and inquest
On the 18th September 2014 commenced an investigation into the death of Martin McCabe aged 66 The investigation concluded at the end of an inquest on the 19hh November 2014. The conclusion of the inquest was Narrative Conclusion "Martin McCabe died as a result of the effects of a head injury which he sustained when he suffered an unwitnessed fall on ward 15 of the Royal Glamorgan Hospital on the 14" September 2014" medical cause of death was 1a. Extensivve Bilateral Subdural Haemorrhage; 2. Myelofibrosis_
Circumstances of the death
Mr McCabe was admitted from an inpatient clinic on the 11' September 2014 onto ward 15 of the Royal Glamorgan Hospital: This was because he was experiencing bleeding from his gastro intestinal tract. This was successfully treated. He was assisted by a nurse on the evening of the 14lh September out of bed to use a 'bed bottle" and was left unattended after which he fell to the ground and suffered a serious injury to his head: A CT scan revealed extensive bilateral subdural haemorrhage as a result of the fall, He passed away the following on the 15th September 2014
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:
Similar PFD reports
Report details
- Reference
- 2014-0505
- Date of report
- 20 November 2014
- Coroner
- Andrew Barkley
- Coroner area
- Powys, Bridgend & Glamorgan Valleys
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: 15 Jan 2015 (estimated from the report date).
Sent to
- Cwm Taf Health Board