The coroner for Mid Kent and Medway, Patricia Harding, has given a verdict on 14 April 2014 after two days of hearing evidence on the circumstances leading up to the death of Mrs Sheila Acott, a 67 year old woman, at Maidstone Hospital on 14 February 2013.

Due to the unexpected nature of her death, the coroner opened an inquest in February 2013 and investigations began. These included obtaining witness statements from the doctors and nurses involved in Mrs Acott’s care, a post mortem and associated investigations.

The matter came before the coroner over the course of 26 March and 14 April 2014 when she heard evidence from some of the doctors and nurses involved in Mrs Acott’s case, as well as those responsible for completing the serious incident report following her fall.  Having heard all of the evidence, the coroner recorded a verdict of accidental death. She found that Mrs Acott was at high risk of falls and on 13 February 2013 she fell when standing unassisted at the nurses’ station in the early hours of the morning. This caused head injuries from which she later died on 14 February 2013. 

The coroner was satisfied that, had the nursing staff known of Mrs Acott’s high risk of falls, on the balance of probabilities, her fall would have been avoided.

BACKGROUND TO THE CASE

Sheila Acott was 67 years old at the time of her death on Thursday, 14 February 2013 while she was an inpatient at Maidstone Hospital, part of the Maidstone and Tunbridge Wells NHS Trust.

Sheila had multiple medical problems including kidney disease, vertigo, aspergillius of the thalamus (fungal spores affecting the brain), arthritis and myelodysplasia (a malignant blood disorder). Although she had been in a fairly poor condition for about two years, she was able to live at home with her husband Ronald who cared for her.  Mr Acott helped her to transfer in and out of bed, to use the commode and to mobilise in the home using a zimmer walking frame.

Over two weeks before her death, Sheila was admitted to the Foster Clark Ward, Maidstone Hospital with an infection and was found to have suffered a bowel perforation. She was treated with antibiotics and was undergoing investigation for suspected deterioration in her malignant blood disorder. Her mobility was restricted to mobilising with a zimmer frame and usually with the assistance of one person for transfers.

MRS ACOTT’S FALL

In the early hours of the morning on Wednesday, 13 February 2013 at approximately 3am, Sheila had a fall and sustained a massive blow to her head. Witness evidence from the nurses present at the time of the fall suggested that Sheila was wandering unaided and without her zimmer frame in an agitated state in the early hours of the morning.

She apparently walked over to the nurses’ station and refused to sit on a chair or put her slippers on. This was out of character for Sheila. The nurses then appear to have sat by the computer while Sheila remained standing on the other side of nurses’ station without any mobility aid or nursing assistance for support. The account is that Sheila suddenly fell backwards and landed “on her head”.

Sheila was found to have a major laceration to the back of her head and was bleeding profusely. A doctor was called to examine her and to suture the wound. She was taken back to bed and the family were informed of the fall several hours later. A decision was made not to CT scan Sheila’s head on the basis that her Glasgow Coma Scale (GCS) score was 14/15, the same as it was normally.

The nursing witness evidence suggests that the nurses were concerned about the severity of the fall and the force of impact on Sheila’s head and on several occasions asked doctors whether a CT head scan should be ordered given the circumstances of the fall, specifically that she fell from her own height backwards directly onto her head without breaking her fall with her arms. A CT scan was not felt to be clinically indicated. Instead, Sheila was to have regular neurological observations which subsequently took place but these appeared to cease approximately 15 hours after the fall.

URGENT BRAIN CT SCAN 36 HOURS AFTER THE FALL

On the morning of 14 February Sheila suffered a massive drop in her GCS level from 14/15 to 5/15 and began bleeding from her mouth and nose. The hospital then performed an urgent brain CT scan more than 36 hours after the fall. The scan showed a massive haemorrhage caused by the fall and the neurosurgeons advised that nothing could now be done for her. The family were informed of the poor prognosis and Sheila died that evening. The post mortem report confirmed the cause of death as head injury.

Mr Ronald Acott, husband of the deceased, and his daughter, Mrs Nicola Davies, instructed Lucie Prothero, associate in the clinical negligence team at Penningtons Manches LLP and David Juckes of Hailsham Chambers to represent them.  In the interim, the Maidstone and Tunbridge Wells NHS Trust carried out its own internal investigation.

FAMILY BELIEVES HER DEATH WAS AVOIDABLE

Commenting after the inquest, Nicola Davies said: “Mum suffered a terrible fall when she was under the care of the hospital which I believe should never have happened if she had been properly looked after.  Since Mum died, we have wanted to understand how she came to suffer such a serious fall when she was in hospital and whether it could or should have been avoided. 

“Losing Mum has been devastating for the whole family and we hope that what happened to her will raise awareness and improve hospital standards, particularly regarding patients’ risk of falls, so that other families are spared the ordeal that we have been through.”

Lucie Prothero commented: “Sheila Acott’s death was a shocking event for the family. No-one ever anticipates that a loved one will suffer a fatal injury while in the care of a hospital.  Ronald and Nicola have long been concerned about how Sheila was looked after at the hospital and needed to know how she came to fall and suffer such a significant injury and why the hospital did not act sooner to check for a brain injury and take appropriate action. The inquest has enabled them to get a better understanding of what happened and how her injuries were sustained.

“Sheila was a vulnerable patient who was unable to mobilise independently without a walking frame and usually needed the assistance of one other person. Despite this, according to the nursing staff, she was permitted to mobilise at night unaided and unsupervised and then left standing at the nurses’ station without any support or a walking frame.

“The family are understandably concerned as to whether the fall would have been avoided if Sheila had been given an appropriate standard of care. To compound matters, the family are concerned that the sad course of events could have been prevented if Sheila was given a CT head scan sooner.”

CORONER’S OBSERVATIONS

Lucie Prothero continued: “The coroner found that a falls risk assessment, manual handling assessment and falls care plan had either been partially completed or not at all. During the 16 days that Sheila was an in-patient before her fall, at no time was the paperwork reviewed by either the ward manager or any of the nursing staff. This meant that the nurses were reliant on their own observations, own experience of Sheila, and verbal handover.

“The coroner learned through questioning the witnesses that the nursing staff  were unaware that Sheila had been determined as being at high risk of falls. The coroner was satisfied that, had the nursing staff known of Sheila’s high risk of falls, on the balance of probabilities, her fall would have been avoided.

“The coroner highlighted the importance of a proper and thorough serious incident investigation. She found that the serious incident report that had been compiled in Sheila’s case was misleading as it failed to identify that the appropriate falls prevention paperwork had not been completed. The trust has promised the family a revised serious incident report which was appreciated.