Inquest order for hospital

At today's inquest, Mr Gwynne told Shrewsbury and Telford Hospital Trust medical director Stephen Evans to ensure lessons were learned from Mr Horobin's death.

It was the first time Mr Gwynne had called a medical director to give evidence during his 35-year career.

Mr Horobin, a quantity surveyor from Avon Dale, Newport, died on February 21, just 36 hours after he was taken to hospital.

The muscular dystrophy sufferer fell twice after being admitted before falling out of bed and fracturing his skull. He died later in the intensive care unit.

He did not have bed rails on his bed at the time of his death on Ward Six. Staff on the Medical Assessment Unit had previously ensured they were fitted to his bed during his stay there.

Mr Gwynne told Mr Evans: "I feel very concerned that the approach in the MAU was not followed in ward six. He fell out of bed, he suffered fatal head injuries from that fall.

"Everybody had good reason to believe that if he did not suffer this head injury he would have been back at home quite shortly after."

Mr Gwynne added: "I would urge you to ensure that your protocols and risk assessments are put in place and followed at all stages. We have got to change."

Recording a narrative verdict, Mr Gwynne said: "The death was one of an accidental nature exacerbated by failure to apply a proper risk assessment and to follow the appropriate protocols."

Mr Evans denied there was a spate of similar deaths at the hospital but said there was a "slight excess" in falls across the trust. He also disputed Mr Horobin had fallen three times but argued that on one occasion staff had supported him and guided him to the floor.

He said the new protocols on bed rails were in place but had not been implemented at the two hospitals at the time of Mr Horobin's death.

He said since the death the falls assessment had been rolled out and a falls prevention team set up.

Mr Evans said: "I don't think we followed our policies to the letter. The main thing we didn't do was document a risk assessment for him.

"The relevant thing was that we didn't complete a bed rail assessment."

Mr Evans told Mr Horobin's widow Susan: "It's our responsibility to say we have got it wrong and it is our responsibility to change these things."

Mr Gwynne said Mr Horobin was "treated adequately and properly but he dies because, to my mind, the risk assessment was not made or not applied to all the way through".

Mr Horobin's widow told the inquest she felt her husband "was neglected".

Mr Gwynne added: "It's a sad and sorry tale. I'm quite convinced that no-one ever expected your husband to die from his admission into hospital.

"I just hope that the lessons which we have to learn from the death of Tony Horobin are going to be taken on board."

By Kirsty Marston