Source · Prevention of Future Deaths
Ian Page
Ref: 2014-0403
Date: 12 Sep 2014
Coroner: Jonathan Layton
Area: Carmarthenshire & Pembrokeshire
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner noted training needs in communication following patient handover, a lack of falls risk assessment and low bed provision for Mr. Page, and a need to review nursing staff levels.
Date
12 Sep 2014
56-day deadline
7 Nov 2014 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner noted training needs in communication following patient handover, a lack of falls risk assessment and low bed provision for Mr. Page, and a need to review nursing staff levels.
View full coroner's concerns
1. There was a training need identified regarding communication following patient handover.
2. No risk assessment was carried out on Mr Page identifying the risk of falls.
3. There was no low bed available to Mr Page.
4. A review of the provision of nursing staff was identified when patient circumstances require greater staffing levels. 2
2. No risk assessment was carried out on Mr Page identifying the risk of falls.
3. There was no low bed available to Mr Page.
4. A review of the provision of nursing staff was identified when patient circumstances require greater staffing levels. 2
Report sections
Investigation and inquest
On 6th May 2014 I commenced an investigation into the death of Ian Page then aged 86. The investigation concluded at the end of the inquest on 12th September 2014. The conclusion of the inquest was one of accidental death. The medical cause of death was: 1(a) fracture of cervical spine 1(b) ischaemic heart disease, fracture of left hip
Circumstances of the death
(1) Mr Page was admitted to Withybush General Hospital on 26th April 2014 following a fall at home. (2) He underwent surgery at the Hospital. Following the operation Mr Page remained in hospital. Mr Page had dementia and would make repeated attempts to leave his bed despite his recent surgery. (3) On the 28th April at approximately 23.10 hours he got up from his bed and fell fracturing his cervical spine. (4) His condition deteriorated and he died on the 2nd May 2014.
Similar PFD reports
Report details
- Reference
- 2014-0403
- Date of report
- 12 September 2014
- Coroner
- Jonathan Layton
- Coroner area
- Carmarthenshire & Pembrokeshire
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: 7 Nov 2014 (estimated from the report date).
Sent to
- Withybush General Hospital