Coroner calls for report after hospital fall death

Former council gardener James Baines, 84, from Pentreclawdd, Gobowen, died on the Cunliffe Ward at the Maelor Hospital, Wrexham.

The inquest was told that information given by his niece – that he had fallen shortly before his admission – was not documented and nurses were not told.

Sister Lynne Hallam told an inquest in Ruthin that she completed a falls risk assessment on Mr Baines when he arrived on the ward from the Clinical Decisions Unit on June 5.

He told her that he was not prone to falling and did not mention his earlier fall that had occurred at an Oswestry restaurant where he and his niece Jill Roberts were having lunch.

Mrs Hallam said he did not have a walking-stick and was able to get into bed from his wheelchair.

She assessed Mr Baines as a medium-to-low risk, but accepted that no special measures had been taken to mitigate that risk and that other staff had not been told of the assessment.

While nurses were holding a safety meeting as part of a shift change on June 6 another patient called to them and Mr Baines was found unconscious on the floor of his cubicle.

Mrs Hallam said that although there was no nurse watching Mr Baines, full-time members of staff were constantly in and out of the room.

Joanne Lees, assistant coroner for North Wales East and Central, said she shared Mrs Roberts’ concern that a risk assessment served little purpose if staff were not made aware and no mitigating steps were taken.

Mrs Roberts told the hearing that Mr Baines had been diagnosed with renal cancer a couple of months earlier but remained active and only occasionally used a walking-stick.

He was taken to the Maelor’s emergency department after blood tests revealed low potassium levels and at that stage Mrs Roberts told doctors and nurses about his fall at lunchtime that day.

His condition deteriorated rapidly after his fall on the ward and he was not considered suitable for surgery. A post-mortem examination revealed the cause of death as subdural haematoma, a bleed on the brain.

An immediate review was carried out at the hospital following his death and the fall was found to have been “unpreventable”.

In recording a conclusion of accidental death, Mrs Lees said she needed to know what action plan, if any, had been introduced by the Betsi Cadwaladr University Health Board as a result before she decided whether she needed to issue a Regulation 28 report to prevent future deaths.