Source · Prevention of Future Deaths
Hilda Thompson
Ref: 2014-0391
Date: 3 Sep 2014
Coroner: Martin Fleming
Area: Surrey
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryAn incomplete management plan on admission led to the patient being wrongly identified as not a falls risk, resulting in a 10-day delay for a full falls assessment. The coroner also noted poor record keeping.
Date
3 Sep 2014
56-day deadline
29 Oct 2014 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
An incomplete management plan on admission led to the patient being wrongly identified as not a falls risk, resulting in a 10-day delay for a full falls assessment. The coroner also noted poor record keeping.
View full coroner's concerns
During the inquest the following concerns arose: ‐
Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. Poor note taking of 2/1/14 to account for this. This left a gap of some 10 days during which she was not properly risk assessed for falls.
I would ask that you consider giving further consideration to the procedures and systems to ensure that there is no further repetition.
Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. Poor note taking of 2/1/14 to account for this. This left a gap of some 10 days during which she was not properly risk assessed for falls.
I would ask that you consider giving further consideration to the procedures and systems to ensure that there is no further repetition.
Report sections
Investigation and inquest
On 30/1/14 I opened the inquest into the death of Hilda Florence Thompson, who at the date of her death was 101 years old. The inquest was resumed and concluded on 27/8/14 I found that the cause of death to be:
1a – Subdural Haemorrhage 1b – Head Injury 2 ‐ Congestive Cardiac Failure
I concluded with a narrative conclusion as follows:
On 1/1/14 Hilda Florence Thompson who had a history of cardiac ill health and asthma was admitted to A&E at East Surrey Hospital with breathlessness, for which she was treated. Subsequently on 19/1/14 she suffered a witnessed collapse causing her to sustain a subdural haemorrhage to which she succumbed and died on 22/1/14.
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1a – Subdural Haemorrhage 1b – Head Injury 2 ‐ Congestive Cardiac Failure
I concluded with a narrative conclusion as follows:
On 1/1/14 Hilda Florence Thompson who had a history of cardiac ill health and asthma was admitted to A&E at East Surrey Hospital with breathlessness, for which she was treated. Subsequently on 19/1/14 she suffered a witnessed collapse causing her to sustain a subdural haemorrhage to which she succumbed and died on 22/1/14.
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Circumstances of the death
Mrs Thompson who had limited mobility and a history of falls was admitted to A&E at East Surrey Hospital on 1/1/14 suffering with breathlessness, where she was treated for possible worsening heart failure and renal function. She was moved from the acute medical unit to Holmwood ward on 8/1/14 where she was identified as a high falls risk. On 19/1/14 she was seen in the corridor adjacent to her room calling for help and holding onto a chair, but had a collapse before the senior nurse could reach her, and she struck her head on the floor. CPR was immediately commenced and she was restored to consciousness. Subsequently a CT scan showed that she had suffered an extensive intracranial injury to which she succumbed and died on 22/1/14.
Copies sent to
Chief Coroner Signed: Mr Martin FlemingDATED this 3rd September 2014
Inquest conclusion
On 1/1/14 Hilda Florence Thompson who had a history of cardiac ill health and asthma was admitted to A&E at East Surrey Hospital with breathlessness, for which she was treated. Subsequently on 19/1/14 she suffered a witnessed collapse causing her to sustain a subdural haemorrhage to which she succumbed and died on 22/1/14.
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Similar PFD reports
Report details
- Reference
- 2014-0391
- Date of report
- 3 September 2014
- Coroner
- Martin Fleming
- Coroner area
- Surrey
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: 29 Oct 2014 (estimated from the report date).
Sent to
- East Surrey Hospital Trust