Source · Prevention of Future Deaths
Agostino Costa
Ref: 2013-0322
Date: 3 Dec 2013
Coroner: M E Hassell
Area: Inner North London
Responses identified: 0 / 1
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Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing of root cause analysis findings.
Date
3 Dec 2013
56-day deadline
20 Apr 2014 est.
Responses identified
0 of 1
Coroner's concerns
Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant safety concerns, exacerbated by inadequate sharing of root cause analysis findings.
View full coroner's concerns
1. There was confusion among the staff as to whether Mr Costa was classified as red (high risk) or green (low risk) in terms of falls.
2. There was confusion among the staff as to whether a patient walking with a frame presents a high risk of falls.
3. There was confusion among the staff as to whether a patient with myelofibrosis and blood transfusions presents a high risk of falls. This confusion was also present in the hospital root cause analysis conducted after Mr Costa’s death.
4. The junior doctor present did not know how to deal with a patient post fall on the ward, though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls.
5. The hospital root cause analysis was not shared with all relevant members of staff, though it was signed off at the beginning of August. Thus learning points from it were completely lost to some.
I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff.
2. There was confusion among the staff as to whether a patient walking with a frame presents a high risk of falls.
3. There was confusion among the staff as to whether a patient with myelofibrosis and blood transfusions presents a high risk of falls. This confusion was also present in the hospital root cause analysis conducted after Mr Costa’s death.
4. The junior doctor present did not know how to deal with a patient post fall on the ward, though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls.
5. The hospital root cause analysis was not shared with all relevant members of staff, though it was signed off at the beginning of August. Thus learning points from it were completely lost to some.
I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff.
Report sections
Investigation and inquest
On 12 May 2013, one of my predecessor coroners, Sean McGovern, commenced an investigation into the death of Agostino Costa, aged 80. I concluded this investigation at the end of the inquest on 28 November 2013.
Circumstances of the death
I concluded that Mr Costa died as a consequence of a terminal disease, though his death was hastened by an accidental fall in hospital at 6.40pm on Sunday, 12 May 2013.
I recorded a medical cause of death of: 1a acute on chronic subdural haemorrhage 1b minor trauma in an individual with chronic idiopathic myelofibrosis.
I recorded a medical cause of death of: 1a acute on chronic subdural haemorrhage 1b minor trauma in an individual with chronic idiopathic myelofibrosis.
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Report details
- Reference
- 2013-0322
- Date of report
- 3 December 2013
- Coroner
- M E Hassell
- Coroner area
- Inner North London
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: 20 Apr 2014 (estimated).
Sent to
- The Whittington Hospital NHS Trust